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MANUAL 


OF   THE 


Practice  of  Surgery 


BY 


W.  FAIRLIE  CLARKE,  M.D.  (oxon.),  F.R.C.S. 

LATE   ASSISTANT-SURGEON  TO   CHARING  CROSS   HOSPITAL 


"Chirurgia  non  quidem  medicamenta  atque  victus  rationem  omittit,  sed  manu  tamen 
plurimum  prsstat."— CelsuS,  Prafat.  Lib.  VII. 


THIRD     EDITION,   REVISED,   ENLARGED, 

AND 

Illustrated  by  One  Hundred  and  Ninety  Engravings  on  Wood 


NEW    YORK 
G.    P.    PUTNAM'S    SONS 

27    &    29    WEST    23D    STREET 
1882 


PREFACE. 


In  preparing  the  third  edition  of  my  Manual  of  Surgery 
I  have  gone  carefully  throiigh  the  text,  revising  it,  and 
endeavouring  to  bring  it  up  to  the  level  of  the  present 
day.  At  the  same  time,  the  number  of  illustrations  has 
been  considerably  increased,  the  Formulary  has  been 
enlarged,  and  many  more  references  to  it  have  been 
introduced  into  the  text. 

The  general  arrangement  and  the  classification  of  disease 
which  have  been  adopted  will  be  Been  at  a  glance  by 
reference  to  the  Table  of  Contents. 

Those  branches  of  Surgery  which  have  undergone  such 
rapid  develojDment  of  late  years  as  to  have  become  almost 
separate  sciences — such,  for  example,  as  the  Surgery  of 
the  Eye  and  of  the  Ear — I  have  considered  only  so  far  as 
a  knowledge  of  them  is  essential  to  every  practitioner. 
Each  of  these  branches  has  called  forth  a  special  literature 
of  its  own,  and  to  this  I  must  refer  those  who  desire 
fuller  information  upon  these  subjects. 

Ever  since  I  was  a  student  it  has  been  my  habit  to 
make  drawings  of  any  cases  of  more  than  usual  interest 
which  came  before  me,  and  many  of  the  illustrations 
which  will  be  found  in  the  following  pages  have  been 
copied  from  sketches  in  my  own  portfolio.  Some  of  the 
others  have  been  taken  from  j^reparations  in  the  Museum 
of  Charing  Cross  Hosi:)ital,  which  were  kindly  placed  at 
my  service  by  the  j\Iodical  Committee. 


viii  PREFACE. 

I  am  well  aware  liow  difficult  it  is  to  give  anything 
like  an  adequate  view  of  the  present  advanced  state  of  oiir 
knowledge  in  the  compass  of  a  small  volume  like  this. 
The  activity  which  is  apj)arent  in  all  departments  of 
Surgery  cannot  fail  to  gratify  those  who  are  interested  in 
the  progress  of  the  Healing  Art ;  but  it  adds  to  the 
difficulty  of  selecting  what  is  of  permanent  value,  and 
presenting  it  in  a  condensed  form. 

I  hope,  however,  that  nothing  which  is  of  real  import- 
ance has  been  omitted,  and  that,  as  far  as  it  goes,  this 
Manual  will  be  found  a  safe  and  trustworthy  guide  to  the 
practice  of  Surgery. 

W.  F.  C. 


November,  1870. 


CONTENTS. 


PAET  I. 

STJKQICAL   DISEASES. 

PAGE 

Local  Hypersemia  .     .' 1 

Active  Congestion 1 

Passive  Congestion 1 

Inflammation 2 

Effusion 10 

Adliesion 10 

Suppuration 11 

Ulceration 16 

Mortification 17 

Processes  of  repair . 21 

Malformations 23 

Hypertrophy 23 

Atrophy  .     .     , 23 

Tumours 23 

Benign 24 

Sarcomatous 32 

Carcinomatous 36 

Scrofula  and  Tuberculosis 44 

PAET  II. 

INJURIES. 

Arrest  of  haemorrhage 48 

Secondary  hsemorrhage 54 

Venous                „                55 

Capillary            „                £5 


X  CONTENTS. 

PAGE 

Bruises 56 

Wouuds 57 

Incised 57 

Contused 60 

Lacerated 60 

Punctured 61 

Gunshot  wounds 62 

Poisoned  wounds 67 

„  „    .   by  healthy  secretions      .......  67 

„  „        by  morbid  products 68 

„  „        by  irritant  poisons 72 

Effects  of  heat 72 

Effects  of  cold 75 

Suspended  animation 76 

PAET  III. 

CONSTITUTIONAL   EXPECTS   OE    STTEGICAL   DISEASES 

AND    INJURIES. 

Collapse — shock 79 

Surgical  or  Traumatic  fever 80 

Hectic  fever 83 

Erysipelas 84 

Pyaemia , 89 

Tetanus 91 

Hysteria 93 

PART  ly. 

DISEASES    AND    INJURIES    OE   VARIOUS   PARTS,   TISSUES, 
AND   ORGANS. 

Diseases  and  injuries  of  the  skin 95 

„  muscles,  tendons,  and  bursa;  .     .  103 

„  bones 110 

„  joints l7l 

,,  arteries 194 

veins 202 


CONTENTS.  xi 

PAGB 

Diseases  and  injuries  of  the  lymphatics 204 

5,                   „                   nerves 205 

head 206 

„                   ,,                   spine 213 

face 220 

eye 224 

ear 249 

„                   ,.                         nose 250 

„                   „                         mouth 254 

„                   ,,                   neck 263 

„                    „                    chest,  inchiding  the  breast     .      .  270 

„                   „                   abdomen,  including  hernia     .     .  277 

„                   „                   rectum  and  anus 296 

„  „  genito-urinary   organs,  including 

the  venereal  diseases      .     .     .  303 

„                   „                   hands  and  feet   ......  354 

PART  Y. 

OPERATIOKS. 

Operations  in  general 364 

Incisions 366 

Anesthetics 366 

Dressings 369 

Constitutional  treatment  after  operations 372 

Venesection 373 

The  cautery,  issues,  setons 374 

Laryngotomy  and  tracheotomy 375 

Ligature  of  arteries 378 

Excision  of  joints    .     .    ' 386 

Amputations 391 


Formulae  and  Receipts 40C 


PART    I. 

SURGICAL  DISEASES. 


XiOCAIi  UYBEItmiailL  OR  COITGESTIOir 

means  the  accumulation  of  blood  which  takes  place  in  a  part  when 
the  vessels  are  overcharged  and  dilated.  Such  accumulation  may 
be  either  active  and  arterial,  or  passive  and  venous. 

Active  congestion  (Determination)  is  a  vital  process  and  de- 
pends upon  an  excess  of  blood  in  the  arteries — this  excess  being 
brought  about  sometimes  by  external  irritation,  sometimes  by 
increased  functional  activity  of  the  organ  or  part.  The  arteries 
are  distended,  and  the  bright  red  blood  flows  through  them  with 
great  rapidity.  Active  congestion  is  not  always  a  morbid  state. 
'J'he  afflux  of  blood  to  the  breast  during  pregnancy  is  a  true  ex- 
ample of  determination.  When,  however,  it  occurs  unnaturally, 
or  interferes  with  healthy  nutrition  or  secretion,  it  becomes  a 
disease.  It  may  be  either  acute  or  chronic.  When  acute,  it 
may  relieve  itself  by  hBemorrhage ;  when  chronic,  it  may  lead  to 
serous  effusions,  or  to  changes  in  the  nutrition  or  secretion  of  the 
part. 

The  treatment  is  that  of  inflammation  in  its  milder  degrees,  and 
will  be  described  hereafter. 

Passive  congestion  is  generally  brought  about  by  mechanical 
causes.  Most  frequently  it  depends  upon  venous  obstruction; 
but  it  may  also  arise  from  general  debility,  or  from  a  want  of 
tone  in  the  vessels  of  the  part,  as  well  as  from  other  causes. 
When  the  circulation  is  only  retarded,  the  blood  flows  slowly 
through  the  distended  vessels;  when,  however,  it  is  altogether 
arrested,  complete  stagnation  takes  place.  If  the  obstruction  be 
removed,  the  circulation  will  soon  recover  itself,  and  the  part  return 
to  its  normal  state.  But  if  the  cause  of  the  disorder  remain  in 
operation,    one  of  two    things    will    speedily  occur — either  the 

B 


2  SURGICAL  DISEASES. 

vessels  will  give  way,  and  allow  the  blood  to  escscge —Jicemorrhaffe ; 
or  the  watery  constituents  of  the  blood  will  make  their  way 
through  the  walls  of  the  vessels,  giving  rise  to  serous  effusion. 

When  a  part  is  passively  congested,  it  is  somewhat  increased  in 
size,  becomes  of  a  dusky  red  colour,  and  pits  on  pressure.  The 
patient  complains  of  a  feeling  of  fulness  and  weight,  with  a 
difficulty  in  movement,  accompanied  by  more  or  less  pain  of  a 
dull  aching  character. 

Treatment. — The  great  object  is  to  remove  the  cause,  be  it  a 
ligature,  tumour,  fsecal  accumulation  or  anything  else.  This  may 
sometimes  be  done  by  merely  studying  the  position  of  the  patient, 
and  facilitating  the  return  of  blood  to  the  heart.  The  next  point 
is  to  relieve  the  distended  vessels.  This  we  effect  by  fomenta- 
tions, counter-irritation,  scarifications,  cupping,  or  leeching. 
Thirdly,  we  should  aim  at  giving  strength  and  tone  to  the  vessels 
themselves  by  bandaging,  friction,  cold-bathing,  and  the  use  of 
stimulating  or  astringent  lotions. 

XXFIdAMMATIOIT 

lies  at  the  root  of  many  surgical  diseases.  It  is,  therefore,  impor- 
tant that  we  should  consider  it  at  some  length. 

When  we  speak  of  inflammation,  we  mean  a  state  which 
depends  essentially  upon  an  alteration  in  the  circulation  of  the 
part,  and  which  reveals  itself  by  outward  marks.  These  local 
changes  are  accompanied  by  certain  constitutional  symptoms, 
which,  taken  together,  are  expressed  by  the  tevva  feverishness  or 
pyrexia. 

The  outward  marks  to  which  we  allude  are  redness,  swelling, 
heat,  and  pain.  "  Notse  inflammationis,"  says  Celsus,  "  sunt 
quatuor,  rubor  et  tumor  cum  calore  et  dolore."  To  these  must  be 
added  impairment  or  loss  of  function.  But  it  must  be  borne  in 
mind  that  not  unfrequently  one  or  more  of  these  symptoms  is 
entirely  absent  or  greatly  modified,  according  to  the  seat  of  the 
disorder  or  the  constitution  of  the  patient. 

To  understand  the  nature  of  inflammation  we  must  look  below 
the  surface,  and  study  the  changes  which  occur  (1)  in  the  circula- 
tion through  the  aflbcted  vessels,  and  (2)  in  the  adjacent  tissues. 

If  the  web  of  a  frog's  foot  is  placed  under  the  microscope  and 
irritated,  it  is  seen  that  the  capillaries  become  dilated  ;  and  the 
blood  stream,  which  was  at  first  accelerated,  is  soon  retarded. 
The  red  corpuscles  crowd  together  in  masses,  while  the  white 
(leucocytes),  which  appear  to  be  increased  in  number,  adhere  to 
the  wi.liS,  or  roll  slowly  along.    Presently  the  circulation  becomes 


INFLAMMATION.  3 

altogether  arrested,  and  stagnation  takes  place  at  various  points. 
When  the  current  of  the  circuh\tion  becomes  very  slow,  the 
minute  arteries  are  nearly  blocked  up  with  red  corpuscles  and 
the  veins  with  leucocytes.  Gradually  these  latter  adhere  to  the 
sides  of  the  vessels,  and,  by  their  own  ama3boid  activity,  pass 
through  them  into  the  surrounding  tissues.  The  red  corpuscles 
also  escape,  though  less  fi*eely.  At  the  same  time  there  is 
transudation  of  the  liijuor  sauffuhns  which  furnishes  the  serous 
eft'usion.  The  migrated  corpuscles  not  only  increase  by  division 
and  rapid  multiplication,  but  they  also  excite  the  tissues  into 
which  they  have  escaped  to  increased  cell-proliferation.  There  is 
greater  nutritive  activity,  and  thus  is  formed  the  cell-growth 
which  plays  such  an  important  part  in  inflammation.  This  new 
cell-growth  is  unstable,  and  easily  breaks  down,  and  forms 
pus.  The  more  intense  the  inflammation,  the  more  rapid  will 
be  the  cell-proliferation,  and  the  lower  the  organization  of  the 
cell  elements. 

During  inflammatory  conditions  of  the  system  the  blood,  as  a 
whole,  appears  to  be  thinner  and  poorer  than  in  its  normal  state.. 
The  red  corpuscles  are  diminished  in  number,  and  have  a  remark- 
able tendency  to  cohere  by  their  flat  surfaces,  both  in  the  body 
and  after  the  blood  has  been  withdrawn  from  it.  The  white 
corpuscles  are  relatively  increased,  while  at  the  same  time  the 
fibrine  may  be  doubled  or  trebled  in  quantity. 

When  inflammatory  blood  is  drawn  from  the  body,  it  coagulates- 
more  slowly  than  healthy  blood ;  and,  as  it  does  so,  the  red 
corpuscles  sink  to  the  bottom,  leaving  the  white  corpuscles  and 
the  tibrine  at  the  top.  The  pale  yellow  layer  thus  formed  is 
called  the  "  bufiy  coat,"  or  the  blood  is  said  to  be  "  bnfled." 
When  the  top  presents  a  depression  in  the  centre  and  elevated 
edges,  it  is  said  to  be  "  cupped "  as  well  as  "  buffed."  These 
appearances,  however,  are  not  peculiar  to  the  inflammatory  state. 
They  are  met  within  the  blood  of  plethoric  persons  and  puerperal 
women,  as  well  as  under  various  other  conditions. 

The  local  changes  that  we  have  described  are  accompanied  by 
certain  constitutional  symptoms,  known  as  symptomatic,  surgical, 
or  irritative  fever — feverishness  or  pyrexia.  There  is  shivering 
or  a  "cold and  hot  fit."  The  pulse  is  quickened;  the  temperature 
is  raised ;  the  skin  becomes  dry,  the  mouth  parched,  the  tongue 
coated,  the  bowels  constipated ;  the  urine  is  scanty  and  throws 
down  a  copious  and  high-coloured  sediment,  and  the  appetite 
fails ;  while  at  the  same  time  the  patient  complains  of  aching 
pains  in  various  parts  of  the  body,  and  of  a  feeling  of  general 
weakness  and  languor. 

The  severity  of  these  symptoms  will  depend  much  lipon  the 

b2 


4  SUEGICAL  DISEASES. 

degree  and  extent  of  the  inflammation,  as  well  as  upon  the  nature 
of  the  part  affected.  They  vary,  too,  according  to  the  constitution 
of  the  patient.  If  he  is  robust  and  plethoric,  the  inflammatory 
lever  will  have  a  sthenic  character,  with  a  flushed  face,  a  bounding 
pulse,  and  a  white  furred  tongue.  If,  on  the  other  hand,  he  is 
feeble  or  debilitated,  the  pyrexia  will  be  of  the  asthenic  kind, 
with  a  vveak  pulse,  a  brown  tongue,  and  a  tendency  to  low 
muttering  delirium. 

Hippocrates  laid  great  stress  upon  the  importance  of  watching 
the  animal  heat ;  and  ever  since  his  time  surgeons  have  made  it 
a  matter  of  observation.  But  it  is  only  of  late  years  that  we 
have  been  able,  by  means  of  the  clinical  thermometer,  to  record 
the  exact  variations  of  the  temperature  from  day  to  day  and  from 
hour  to  hour.  The  information  which  this  little  instrument  gives 
us  is  of  the  utmost  value  in  all  inflammatory  diseases. 
For  the  varieties  of  Surgical  Fever,  see  p.  80. 
Spread  of  ivflammation. — Inflammation  may  spread  in  several 
ways : — (1)  by  continuity,  along  the  same  tissue;  (2)  by  contiguity, 
from  one  tissue  to  an  adjacent  one ;  (3)  by  metastasis,  the  disease 
suddenly  leaving  one  part  and  appearing  in  another;  or  (4)  morbid 
material,  capable  of  exciting  inflammation,  may  ^e  carried  by 
the  blood  from  one  point  to  another,  as  in  pyaemia. 

Termination  of  inflammation. — There  are  two  ways  in  which 
inflammation  may  terminate  : — (1)  by  the  death  of  the  patient, 
from  the  severity  of  the  attack,  from  the  exhaustion  produced  by 
its  long  continuance,  or  from  the  vital  importance  of  the  part 
affected:  (2)  by  resolution.  The  circulation  may  recover  itself; 
healthy  nutrition  may  be  restored  ;  any  effusion  that  has  occurred 
may  be  absorbed ;  secretion  may  be  re-established,  and  the  part 
may  return  in  every  respect  to  its  normal  state. 

These  are  the  only  ways  in  which  inflammation  can  properly 
be  said  to  terminate.  There  are,  however,  certain  secondary 
processes : — Effusion,  adhesion,  suppuration,  ulceration,  and  mor- 
titication — which  are  often  spoken  of  as  terminations,  but  which 
are  more  correctly  called  the  events  of  inflammation.  To  each 
of  these  conditions  we  shall  allude  presently. 

Local  effects  of  inflammation. — These  are  of  the  most  oppo- 
site kinds — induration  and  softening,  enlargement  and  atrophy ; 
but  they  may  all  be  regarded  as  the  result  of  imperfect 
resolution. 

Induration  occurs  after  long-standing  inflammation  with  effu- 
sion, as  the  result  of  the  interstitial  deposit  of  plastic  material. 
Softening  follows  the  more  acute  forms  of  inflammation,  as  the 
result  of  impaired  nutrition.  Again,  mflammation  sometimes  leads 
10  ail  increase  of  bulk  Irom  enlargement  of  the  vessels,  effusion 


INFLAMMATION.  5 

and  cell-growth.     Sometimes,  on  the  contrary,  its  effect  is  to  pro- 
dnce  a  decrease  of  size,  by  interstitial  absorption. 

Varieties  of  inflammation. — Inflammations  are  classified  ac- 
cording to  their  duration,  or  their  character. 

Thus  we  speak  of  them  as  acute,  subacute  or  chronic,  accord- 
ing to  the  time  that  they  last.  The  acute  run  a  short  course ; 
the  subacute  a  soinewhat  longer;  while  the  chronic  have  a 
tendency  to  become  indefinite  in  tlieir  duration.  Or,  if  we  look 
to  the  character  of  the  inflammation,  we  speak  of  it  as  healthy  or 
unhealthy,  circumscribed  or  diff'use,  strumous,  syphilitic,  &c. 

The  causes  of  i)ifl.ammation  are  (1)  predisposing,  (2)  exciting ; 
and  in  each  case  they  may  act  locally,  or  through  the  medium  of 
the  constitution. 

Local  predisposing  causes  are  such  as  these : — The  habitual 
over-use  of  a  part — for  example,  of  a  joint;  a  chronic  state  of 
congestion  ;  a  previous  attack  of  inflammation. 

The  constitutional  predisposing  causes  are  those  which  impair 
the  purity  of  the  blood,  whether  it  be  by  excessive  stimulation,  or 
by  a  want  of  proper  nourishment.  Thus,  it  is  well  known  that 
indulgence  at  table  predisposes  to  gouty  inflammations ;  while,  on 
the  other  hand,  the  poor  and  persons  of  a  strumous  habit,  whose 
vital  powers  are  enfeebled,  are  especially  liable  to  other  forms 
of  inflammatory  disease. 

The  local  exciting  causes  are  obvious.  We  need  only  mention 
injuries,  contusions,  wounds,  scalds,  &c. 

The  constitutional  exciting  causes  are  those  states  of  the  blood 
wherein  it  would  appear  that  a  morbid  material  accumulates, 
until  it  manifests  itself  in  a  local  inflammation — as,  for  example, 
carbuncle,  gout,  acute  rheumatism,  &c. 

Treatment  of  infl-ammation. — In  considering  this  subject  we 
must  fall  back  upon  the  classification  which  we  have  already 
given,  and  speak  first  of  the  treatment  of  acute  inflammation. 
When  such  a  disease  occurs  in  young  and  robust  persons  it  calls 
for  prompt  and  energetic  measures.  Sthenic  inflammation  is 
much  under  control,  and  we  are  often  able  to  exercise  more  influ- 
ence over  it  than  we  can  over  the  other  varieties. 

The  first  thing  is  to  remove  the  cause,  if  it  be  possible  to  do  so. 
Thus,  if  a  joint  is  inflamed  from  excessive  use,  it  must  be  kept 
at  rest ;  if  an  eye  is  inflamed  from  the  presence  of  particles  of  sand, 
they  must  be  taken  away. 

The  next  point  is  to  diminish  the  flow  of  blood  to  the  part, 
and  this  may  be  done  either  through  the  medium  of  the  consti- 
tution, or  by  local  means.  The  sum  of  such  measures  forms 
what  is  called  the  antiphlogistic  treatment. 

Constitutional  treatment  of  acute  inflammation  of  the  sthenic 


6  SUEGICAL  DISEASES. 

type. — In  tlie  first  place,  everything  which  can  irritate  the 
patient,  whether  in  body  or  mind,  should  be  removed.  He 
should  be  kept  at  rest  in  a  well-regulated  temperature,  and 
placed  upon  a  low  diet.  We  must  then  consider  what  can  be 
done  for  him  by  medical  treatment)  properly  so  called. 

The  most  powerful  weapon  that  we  possess  for  subduing  acute 
inflammation  is  Mood-letting.  But  it  is  a  weapon  which  must 
not  be  used  without  great  caution,  especially  in  the  case  of  the 
young  or  the  old,  or  in  persons  whose  vital  powers  are  enfeebled 
from  ill-health,  dissipation,  or  any  other  cause.  It  is  so  easy  to  let 
hlood,  and  so  difficult  to  restore  it,  that  it  is  only  when  some 
organ  of  primary  importance  is  in  danger  that  we  are  justified  in 
having  recourse  to  this  remedy. 

Happily  we  have  other  means  at  our  disposal,  which  are  very 
efifectual  in  reducing  inflammation,  and  which  are  not  open  to  the 
same  objections  as  bleeding.  These  are  purgative,  diaphoretic, 
and  diuretic  medicines. 

In  almost  all  cases  of  inflammation  it  is  right  to  give  a  free 
purge  at  the  outset  of  treatment.  The  exceptions  to  this  rule 
are  certain  cases  of  abdominal  inflammation,  when  we  desire  to 
keep  the  bowels  quiet  rather  than  to  excite  tbem  to  action. 
Perhaps  for  an  adult  the  best  purge  that  can  be  given  is  a 
mercurial,  followed  by  a  saline  or  aloetic  draught — e.g.,  5  grains 
of  blue  pill  at  night,  followed  next  morning  by  ^j  of  the  mist, 
sennse  co.,  or  of  the  decoct,  aloes  co.,  or  a  seidlitz  powder.  This 
has  the  eSect  of  clearing  the  primce  vice,  promoting  the  secretions 
and  relieving  the  circulation.  It  may  be  necessary  to  repeat  this 
remedy  from  time  to  time  as  the  case  proceeds. 

If  we  use  diaphoretic  or  diuretic  medicines  their  action  must  be 
kept  up  by  doses  given  every  three  or  four  hours.  Antimonials  often 
answer  admirably  by  encouraging  perspiration  and  tranquillizing 
the  circulation.  At  the  same  time,  the  skin  and  the  kidneys 
may  be  stimulated  by  salines,  such  as  the  acetate  of  ammonia, 
or  the  nitrate  of  potash.     (F.  33,  55,  64,  69.) 

Mercury  has  a  time-honoured  reputation  for  allaying  inflamma- 
tion, especially  in  serous  and  fibrous  membranes.  Of  late  years, 
however,  its  value  in  this  respect  has  been  called  in  question ;  but 
there  can  be  little  doubt  that  it  is  a  useful  remedy  in  acute  inflam- 
mations of  a  sthenic  type,  particularly  when  combined  with 
opium.  Its  action  seems  to  be  that  of  an  alterative,  promoting 
secretion  and  moderating  the  force  of  the  heart.  But  besides 
this,  it  would  appear  to  exert  a  special  influence  over  the  fibrine 
of  the  blood  by  diminishing  its  quantity.     (P.  82.) 

Opium  is  of  great  service  in  allaying  pain,  soothing  the  patient, 
and  procuring  sleep.     In  the  form  of  Dover's  powder  it  is  in- 


INFLAMMATION.  7 

valuable.  Its  use  in  combination  with  mercury  has  been  already 
mentioned. 

Local  treatment  of  actde  inflammation  of  the  sthenic  type. — 
Local  blood-letting  is  a  practice  much  in  vogne  at  the  present 
day,  and  may  almost  be  said  to  have  superseded  venesection. 
Undoubtedly  it  gives  us  many  of  the  good  effects  of  general 
bleeding,  without  the  disadvantages  which  belong  to  that  method 
of  depletion. 

It  may  be  carried  out  in  a  variety  of  ways — by  incisions, 
scarifications,  cupping,  or  leeches.  • 

Incisions  are  specially  applicable  to  the  skin  when  it  is 
stretched  in  such  a  way  that  it  is  in  danger  of  sloughing.  A 
number  of  small  cuts  should  be  made  with  a  lancet  in  parallel 
rows,  extending  only  to  the  depth  of  the  true  skin. 

Scarification  is  chiefly  used  when  the  inflammation  attacks  the 
mucous  membranes — as,  for  example,  the  lining  of  the  mouth  or 
the  gums.  In  quinsey  it  is  a  good  practice  to  scarify  the  most 
prominent  part  of  the  tonsil. 

Cupping  is  an  efficient  means  of  removing  blood,  and  relieving 
the  over-burdened  circulation.  It  is,  however,  more  suited  to 
deep-seated  than  to  superficial  inflammation.  The  cupping-glasses 
should  not  be  placed  upon  the  inflamed  spot ;  nor  should  the 
scarificator  be  used  in  parts  which  are  left  uncovered  by  the 
dress — as,  for  example,  the  neck — because  the  scars  are  apt  to 
remain  for  life.  The  "artificial  leech"  is  a  modification  of  cup- 
ping, which  is  well  adapted  to  some  deep-seated  and  localized 
inflammations — for  example,  those  of  the  eye. 

Leeches  are  extremely  useful  in  allaying  acute  inflammation. 
They  should  be  placed,  not  upon,  but  around,  or  in  the  neighbour- 
hood of,  the  disease.  They  should  be  used  in  sufficient  numbers 
to  produce  a  marked  effect.  It  is  estimated  that  each  leech  ab- 
stracts fully  half  an  ounce  of  blood.  There  are  some  situations 
in  which  they  ought  not  to  be  employed — for  example,  on  the 
scrotum,  or  eyelids,  for  fear  there  should  be  difficulty  in  prevent- 
ing haemorrhage  or  ecchymosis;  nor  near  specific  sores,  lest  the 
bites  should  become  affected  with  the  morbid  poison. 

Bleeding  may  be  encouraged  by  warm  poultices  or  fomentations. 
On  the  other  hand,  it  may  be  arrested  by  pressure  or  styptics, 
such  as  the  tincture  of  the  perchloride  of  iron,  powdered  matico, 
or  lunar  caustic. 

Warmth,  particularly  when  conjoined  with  moisture,  is  a 
remedy  of  the  utmost  service  in  acute  inflammation.  It  may  be 
applied  either  in  the  form  of  a  poultice  or  a  fomentation,  and  both 
these  methods  maybe  rendered  more  efficient  by  medication.  The 
poultice  may  be  mixed  with  laudanum  or  tincture  of  henbane  j  or 


8  SURGICAL  DISEASES. 

in  making  the  fomentations  a  decoction  of  poppy  heads  or  chamo- 
mile flowers  may  be  used  instead  of  plain  water.  Warmth  and 
moisture  are  particularly  applicable  when  the  inflammation  is 
at  its  height.  They  relieve  tension,  mitigate  pain,  and  promote 
suppuration.  But  for  the  earlier  stages,  while  suppuration  may 
yet  be  averted,  as  well  as  for  the  later,  cold  will  often  be  found 
a  more  useful  remedy.  In  deciding  whether  to  have  recourse  to 
warm  or  cold  applications,  it  may  sometimes  be  well  to  consult 
the  patient's  feelings,  and  to  see  which  gives  him  the  most  relief. 
The  general -rule,  however,  is  as  we  have  stated — namely,  that 
when  the  inflammation  is  at  its  height,  warm  and  moist  applications 
will  be  found  the  most  efiicient,  while  cold  will  be  more  useful  in 
the  earlier  and  later  stages.  When  cold  is  employed  in  the  early 
stage  of  an  inflammation  it  is  with  the  view  of  anticipating  the 
morbid  action,  and  preventing  its  further  progress.  Thus,  a 
wound  of  a  joint,  threatening  the  most  serious  consequences,  may 
sometimes  be  conducted  to  a  successful  result  by  the  use  of  a 
splint,  and  the  continuous  application  of  cold.  In  the  later 
stages  of  acute  inflammation,  cold  is  of  great  use  in  giving  tone  to 
the  vessels,  and  preventing  a  congested  state  of  the  part,  which  is 
apt  to  remain  after  the  more  urgent  symptoms  h^ve  subsided. 
It  may  be  applied  by  irrigating  the  part  with  cold  water,  or  by 
covering  it  with  evaporating  lotion  ;  or  more  eff"ectually  by  an  ice 
poultice  (F.  97),  or  by  a  bladder  or  india-rubber  bag  filled  with 
pounded  ice,  or  ice  and  salt,  and  laid  upon  the  part. 

The  treatment  of  acute  inflammation  of  the  asthenic  type  must 
not  be  in  the  slightest  degree  antiphlogistic.  Depletion  would  do 
harm  instead  of  good.  Everything  which  is  calculated  to  lower 
the  patient  should  be  carefully  avoided.  Locally  we  must  con- 
fine ourselves  to  the  milder  and  more  soothing  measures  that  have 
been  mentioned,  poultices,  fomentations,  &c. 

It  is  the  general  health  which  is  at  fault,  and  to  this  we  must 
address  ourselves.  We  must  examine  the  state  of  the  pulse, 
tongue,  skin,  and  secretions.  If  the  pulse  is  rapid  and  weak,  the 
tongue  brown  and  covered  with  sordes,  and  the  skin  hot  and  dry, 
we  must  have  recourse  to  a  stimulating  and  supporting  plan  of 
treatment.  A  light  but  nourishing  diet  should  be  given,  com- 
bined with  a  little  wine  or  brandy.  We  must  take  care  that  the 
patient  has  a  proper  and  sufl[icient  diet  on  the  one  hand,  and  that 
he  is  not  over-stimulated  on  the  other.  The  medical  treatment 
consists  in  clearing  out  the  bowels  by  a  gentle  purgative,  and 
then  giving  salines  with  carbonate  of  ammonia,  ether,  bark,  and 
similar  drugs.  The  action  of  the  skin  may  be  promoted  by 
diaphoretics,  while  restlessness  and  irritability  are  allayed  by 
opium. 


INFLAMMATION.  9 

Treatment  of  chronic  inflammation. — Chronic  inflammation — 
that  is  to  say,  an  inflammation  which  tends  to  last  an  indefinite 
time — may  depend  either  upon  a  continued  source  of  irritation, 
or  upon  relaxation  of  the  vessels  following  an  acute  attack.  Our 
first  business  must  be  to  ascertain  the  cause  of  the  disease.  If 
this  should  pi'ove  to  be  irritation,  we  must  endeavour  to  remove 
or  allay  it.  Should  it  be  a  relaxed  and  dilated  state  of  the  vessels 
of  the  part,  we  must  try  and  restore  their  healthy  tone. 

The  source  of  irritation  is  sometimes  local — as,  for  example,  a 
foreign  body  or  a  morbid  growth.  But  much  more  frequently  it 
has  a  constitutional  origin,  and  depends  upon  a  strumous  habit,  or 
a  disordered  digestion,  or  a  faulty  state  of  the  secretions. 

If  the  irritation  is  kept  up  by  the  presence  of  a  foreign  body, 
we  must  consider  whether  it  admits  of  removal ;  or,  if  not,  how 
far  its  effects  may  be  mitigated.  If,  however,  the  irritation 
arises  from  an  impaired  digestion,  great  benefit  may  be  derived 
from  a  regulated  diet,  combined  with  moderate  exercise  in  the 
open  air,  and  the  use  of  aperient,  alterative,  or  tonic  medicines. 
Small  doses  of  grey  powder  or  Plummer's  pill  may  be  given  at 
short  intervals,  and  continued  for  a  length  of  time,  but  they  must 
never  be  allowed  to  produce  salivation.  When  nsed  in  this  way 
mercury  has  a  double  value.  It  serves  to  subdue  inflammation, 
and  at  the  same  time  it  promotes  the  absorption  of  the  eff"used 
material.  Iodide  of  potassium,  in  addition  to  its  antisyphilitic 
properties,  is  useful  as  an  alterative  and  absorbent. 

If  the  patient  is  of  a  strumous  habit,  we  must  prescribe  cod- 
liver  oil,  or  the  preparations  of  iron  and  quinine ;  taking  care  at 
the  same  time  that  the  diet  is  light,  nutritious,  and  given  with 
regularity. 

If  the  chronic  inflammation  depends  upon  a  relaxed  state  of  the 
vessels  of  the  part,  we  must,  in  addition  to  constitutional  remedies, 
resort  to  local  measures.  The  distended  vessels  may  be  relieved 
from  time  to  time  by  local  bleeding,  w'hile  we  endeavour  to  im- 
part strength  and  elasticity  to  their  coats  by  stimulating  or 
astringent  applications,  such  as  the  sulphates  of  zinc  or  copper, 
or  the  nitrate  of  silver. 

Friction  is  very  useful  in  cases  of  this  kind ;  particularly  if  some 
stimulating  liniment  is  rubbed  in  at  the  same  time,  and  the 
rubbing  conducted  in  such  a  manner  as  to  promote  the  venous 
circulation. 

Counter-irritation,  by  means  of  blisters,  setons,  issues,  the 
actual  cautery,  or  rubefacient  embrocations,  is  one  of  the  most 
efficient  remedies  that  we  possess  for  removing  chronic  inflamma- 
tion. 

Rest  and  equahle  jpresaure  by  means  of  a  well-adjusted  bandage 


10  SUEGICAL  DISEASES. 

are  often  of  the  first  inrportance,  and  without  them  the   other 
measures  I  have  enumerated  are  frequently  of  little  avail. 

Culd  sponging,  or  the  use  of  a  cold  douche  bath,  is  a  very  simple 
and  at  the  same  time  a  very  efficacious  remedy.  This  may  often 
be  employed  in  conjunction  with  some  of  the  other  means  already 
mentioned,  as  friction  and  bandaging. 

EFFUSZOXO'. 

EjBFusion — the  escape  of  some  of  the  constituents  of  the  blood — 
is,  as  we  have  seen,  an  integral  part  of  the  inflammatory  process. 
But  effusion  occurs  also  as  the  result  of  passive  congestion ;  and 
both  these  conditions  are  of  so  much  interest  to  the  surgeon  that 
we  shall  devote  a  brief  section  to  their  consideration. 

The  effusions  which  are  met  with  in  surgical  practice  some- 
times consist  of  blood,  sometimes  of  liquor  sanguinis,  sometimes 
of  serum. 

When  blood  is  effused  it  is  by  the  rupture  of  some  of  the 
minute  vessels.  The  effusion  of  liquor  sanguinis  is,  properly 
speaking,  a  transudation.  The  watery  portion  of  the  blood,  hold- 
ing the  fibrine  in  solution,  escapes,  while  the  corpuscles  are  left 
behind.  The  fluid  drawn  by  a  blister  is  liquor  sanguinis.  But 
the  most  common  effusion  is  the  serous.  The  fluid  that  is  poured 
out  usually  contains  a  small  quantity  of  fibrine,  together  with  a 
large  amount  of  albumen.  When  such  effusion  occurs  in  the 
serous  cavities,  it  gives  rise  to  clrojisies ;  when  it  takes  place  in 
the  cellular  tissue,  it  occasions  oedema.  When  the  serum  has  been 
absorbed,  and  the  fibrine  deposited  in  the  tissues,  the  condition 
known  as  solid  oedema  is  produced. 

ABHESIVZ:    ZI^FZiAMIVIATZON'. 

Inflammation  is  said  to  be  adhesive  when  it  leads  to  the  effusion 
of  fibrine,  lymph,  or  plastic  material.  The  study  of  this  variety 
of  inflammation  is  of  great  importance,  because  it  is  the  medium  by 
which  the  natural  reparative  processes  are  carried  out  in  a  large 
majority  of  cases.  Effused  lymph  is  met  with  in  two  states. 
Sometimes  it  is  healthy,  'plastic,  fibrinous ;  at  other  times  it  is 
unhealthy,  aj)lastic,  corpuscular.  These  are  the  terms  in  general 
use  to  distinguish  the  two  kinds  of  lymph.  The  former  is  the 
"coagulable  lymph,"  properly  so  called.  It  contains  a  large  {pro- 
portion of  fibrine,  and  tends  to  become  organized.  The  latter  is 
composed  chiefly  of  corpuscles,  suspended  in  a  thin  serous  fluid, 
and  it  tends  to  degenerate.  Such  degeneration  often  takes  the 
form  of  an  unhealthy  suppuration.     For  the  sake  of  clearness,  the 


SUPPUEATION.  U 

two  kinds  of  lymph  may  be  contrasted  with  one  another  in  tliis 
way.  But  in  practice  they  are  found  blended  and  intermingled 
in  an  endless  variety  of  proportions.  It  is  hardly  too  much  to 
say  that  no  two  specimens  are  exactly  alike. 

When  lymph  has  been  effused,  it  may  undergo  absorption, 
development,  or  degeneration. 

When  lymph  is  absorbed  it  probably  first  breaks  down,  and 
is  carried  away  as  debris.  The  part  is  then  restored  to  its  natural 
state. 

Coagulable  lymph  is  capable  of  being  organized  into  a  variety 
of  forms ;  for  it  is,  as  we  have  said,  the  medium  through  which 
Nature  effects  all  her  reparative  processes.  It  passes  through  the 
form  cither  of  "  nucleated  blastema,"  or  of  a  mass  of  nucleated 
cells,  and  becomes  fibrous  or  fibro-cellular.  It  is  then  more  fully 
developed,  and  gradually  approaches  the  characters  of  the  tissue 
which  has  to  be  repaired.  It  is  only  the  simpler  tissues  which 
are  perfectly  reproduced ;  while  the  place  of  the  more  complex 
ones  is  supplied  by  an  imperfect  substitute. 

The  way  in  which  lymph  becomes  organized  is  an  interesting 
question.  It  is  now  held  by  most  observers  that  offsets  from 
existing  vessels  enter  it  at  its  margins,  and,  by  forming  a  series 
of  loops  or  arches,  ultimately  pervade  the  whole  mass. 

The  degeneration  to  which  lymph  is  liable  is  of  two  kinds. 
It  may  wither  into  a  dry  and  horny  substance,  or  it  may  become 
granular  and  fatty. 

SUPFURATIOIT. 

Suppurative  inflammation  is  that  variety  which  leads  to  the 
formation  of  pus. 

Healthy  or  laudable  pus  is  a  thick,  opaque  fluid,  of  a  yellowish- 
white  colour,  a  faint  odour,  and  generally  of  an  alkaline  reaction. 
Under  the  microscope  it  is  found  to  consist  of  a  thin  fluid, 
tlie  liquor  puris,  and  corpuscles.  The  greater  the  number  of  cor- 
puscles, the  better  is  the  quality  of  the  pus.  Sometimes  it  is 
mixed  with  blood,  and  then  it  is  said  to  be  sanious ;  sometimes  it 
is  watery  and  acrid,  when  it  is  termed  ichorous ;  sometimes  it  is 
curdy,  and  contains  flakes  of  coagulated  lymph.  These  are  some 
of  the  chief  varieties  of  pus  that  occur  in  practice  ;  but,  whatever 
its  particular  characters,  it  is  never  met  with  except  as  the  result 
of  inflammation.  The  corpuscles  may  be  regarded  as  exudation- 
cells,  and  the  liquor  puris  as  serum,  modified  by  the  progress 
of  the  inflammatory  action. 

In  most  cases  pus  may  be  easily  recognised  by  its  appearance, 
or  by  its  becoming   viscid  und  ropy  on  the  addition  of  liquor 


12  SURGICAL  DISEASES. 

potasscB.  If,  however,  any  diflBculty  should  arise,  the  microscope 
will  generally  enable  us  to  distinguish  it  from  tubercle,  cancer, 
softened  fibrine,  turbid  serum,  or  other  substances  with  which  it 
might  be  confounded. 

Pus  may  either  be  formed  on  a  free  surface,  as,  for  example, 
on  a  mucous  membrane ;  or  deeply  among  the  tissues.  In  the 
latter  case  it  constittites  an  abscess. 

Suppuration,  whether  superficial  or  deep,  may  be  either  acute 
or  chronic ;  it  may  run  its  course  in  a  few  days,  or  it  may  last  for 
months  or  even  for  years. 

Again,  it  may  be  either  circumscribed  or  diffused.  When 
suppuration  takes  place  in  a  healthy  individual,  the  lymph,  which 
is  poured  out  in  the  early  stage  of  the  inflammation,  serves  as  a 
boundary  wall  and  limits  the  spread  of  the  suppuration.  But 
when  the  patient's  constitution  is  broken,  no  such  barrier  is 
formed,  and  the  suppurative  inflammation  becomes  diffuse. 

When  pus  is  about  to  be  formed  on  a  free  surface,  we  observe 
the  ordinary  signs  of  acute  inflammation. 

When  an  acute  abscess  is  about  to  form  there  are  some  ad- 
ditional points  which  may  be  noticed.  The  pain  has  a  throbbing 
character.  The  skin  becomes  tense,  shining,  and  sometimes  oede- 
matous.  In  the  course  of  a  short  time,  fluctuation  may  be 
detected — that  is  to  say,  when  a  finger  is  placed  on  each  side 
of  the  swelling,  and  pressure  is  made  from  one  point  to  the  other, 
a  peculiar  sensation  is  communicated,  which  indicates  the  presence 
of  fluid. 

Suppuration,  like  other  events  of  inflammation,  is  commonly 
attended  by  certain  constitutional  symptoms.  There  is  feverish- 
ness,  with  loss  of  appetite,  and,  when  matter  has  begun  to  form, 
there  are  "  chills  and  heats,"  or  perhaps  distinct  rigors. 

When  the  discharge  of  pus  is  profuse  and  long-continued,  it  is 
apt  to  give  rise  to  hectic.     {See  Hectic.) 

In  the  case  of  a  chronic  abscess  the  signs  are  somewhat  obscure; 
neither  the  local  nor  the  constitutional  symptoms  are  well-marked. 
An  indolent,  circumscribed  swelling  appears,  which  is  indistinctly 
fluctuating,  and  free  from  pain  or  tenderness.  If  it  happens  to 
be  enclosed  in  a  tough  cyst,  the  difficulty  of  diagnosis  will  be 
increased.  When  it  approaches  the  surface  it  becomes  painful, 
involves  the  skin,  ulcerates,  and  discharges  itself. 

Sometimes  the  inflammation  which  precedes  suppuration  is  so 
slight,  or  so  slow  in  its  progress,  that  it  excites  no  uneasiness, 
until  a  swelling  is  detected  containing  pus.  Such,  at  least,  would 
seem  to  be  the  pathology  of  cold  abscesses. 

What  circumstances  conduce  to  suppuration  ?  How  comes  it 
that  in  one  case  inflammation  gives  rise  to  adhesion,  while  in 


SUPPURATION.  13 

another  it  leads  to  the  formation  of  pus  ?  This  seems  to  depend 
upon  the  quality  of  the  eifused  material.  In  proportion  as  it  is 
healthy  or  fibrinous,  adhesion  is  likely  to  take  place ;  while,  on 
the  other  hand,  in  proportion  as  it  is  lanhealthy  or  corpuscular,  it 
is  prone  to  suppurate.  In  truth,  there  is  but  a  step  between  the 
exudation-cell  and  the  plus-globule. 

The  quality  of  the  effusion  depends  in  a  great  degree  on  the 
state  of  the  patient's  health ;  when  this  is  good,  the  character  of 
the  eff"Msion  will  be  good  also,  and  vice  versa. 

Again,  the  seat  of  the  disease  influences  the  nature  of  the 
effusion :  mucous  membranes  very  readily  suppurate ;  serous 
membranes  but  seldom. 

Again,  the  access  of  air  seems  to  promote  suppuration. 
Hence  the  advantage  of  a  subcutaneous  incision  to  which  little  or 
no  air  is  admitted. 

The  treatment  of  suppuration  is  partly  local  and  partly  consti- 
tutional. 

Locally,  we  must  try  to  take  away  the  cause,  if  it  be  a  foreign 
body,  a  piece  of  dead  bone,  or  anything  else  that  is  capable 
of  removal.  Such  things  are  often  the  causes  of  chronic  abscess. 
Then  we  must  endeavour  to  reduce  the  inflammation,  by  study- 
ing the  position  of  the  part,  and  by  using  cold  lotions,  water- 
dressing,  fomentations,  or  poultices,  as  the  case  may  require. 
Lastly,  we  must  give  a  favourable  exit  to  the  pus,  and  do  what 
we  can  by  antiseptic,  stimulating,  or  astringent  applications,  to 
bring  about  a  more  healthy  action,  and  to  limit  the  amount  of 
discharge. 

An  acute  abscess  should  be  covered  with  a  poultice  made  of 
bread,  bran,  chamomile  flowers  or  linseed-meal.  As  soon  as 
fluctuation  is  detected,  a  sufficient  incision  should  be  made  to  let 
out  the  pus,  and  the  poultice  continued. 

A  chronic  abscess  will  often  require  to  be  laid  freely  open, 
stuffed  with  lint,  and  allowed  to  heal  from  the  bottom. 

In  the  case  of  a  large  chronic  abscess — connected  with  disease 
of  the  spine,  for  example — it  is  best  to  make  a  small  valvular 
incision,  that  is  to  say,  to  pass  the  knife  obliquely  under  the  skin 
for  a  short  distance  before  it  reaches  the  cavity ;  or  the  air-tight 
syringe,  known  as  the  "  aspirator,"  may  be  used.  By  these 
means  the  entrance  of  air  is  prevented,  while  the  uiatter  is 
drawn  off",  a  little  at  a  time,  on  repeated  occasions,  so  as  to 
allow  the  walls  of  the  abscess  to  contract  gradually. 

The  Aspirator  represented  in  Pig.  1  is  portable  and  convenient, 
for  it  can  be  fitted  to  an  ordinary  bottle.  When  it  is  to  be  used, 
the  right  stop- cock  is  closed,  the  left  opened,  and  the  air  in  the 
bottle  exhausted  by  a  few  strokes  of  the  piston.    The  lett  stop- 


14 


SURGICAL  DISEASES. 


cock  is  then  closed,  the  needle  introduced  into  the  abscess,  and 
the  riglit  stop-cock  opened.  The  fluid  will  then  run  up  the  tube, 
and  fall  into  the  bottle. 

Fi-.  1. 


Pneumatic  aspirator. 

The  older  surgeons  used  to  regard  suppuratioi»  with  more 
favour  than  we  do  at  the  present  time.  With  certain  exceptions 
it  is  scarcely  too  much  to  say  that  the  modern  surgeon  wishes  to 
prevent  altogether  the  formation  of  pus,  and  that  the  aim  of 
surgery  in  this  respect  is  to  counteract  the  irritating  influence  of 
putrefaction,  so  as  to  reduce  all  wounds,  as  it  were,  to  the  condi- 
tion of  subcutaneous  injuries.  Many  attempts  have  been  made 
to  eflfect  this  object,  and  various  methods  of  practice  have  been 
suggested ;  but  the  most  successful  is  undoubtedly  that  which 
has  been  introduced  by  Professor  Lister.  I  have  had  the  advan- 
tage of  witnessing  the  antiseptic  system  as  it  is  carried  out  in  his 
wards,  and  I  cannot  doubt  its  value.  I  shall,  therefore,  briefly 
describe  it. 

Mr.  Lister  has  found  no  substance  so  convenient  for  antiseptic 
dressings  as  carbolic  acid.  He  employs  a  watery  solution  (1  to 
100),  an  oily  solution  (1  to  10  of  olive  oil),  a  gauze  impregnated 
witli  carbolic  acid  in  paraffin,  and  a  protective  plaster  of  silk 
coated  with  copal  varnish,  containing  no  carbolic  acid,  but 
intended  to  protect  raw  surfaces  from  the  immediate  contact  of 
what  would  act  as  an  irritant.  With  the  watery  solution  milder 
cases  are  dressed,  and  an  antiseptic  atmosphere  is  kept  up  around 
h  wound  by  means  of  a  spray-producing  apparatus  during  the 
time  that  it  is  being  examined.  With  the  oil  the  hands  of  the 
surgeon  and  his  instruments  are  smeared;  and  sometimes  the 
ligatures  and  the  dressings  are  saturated  with  it.     The  anti- 


SUPPUEATION.  15 

septic  gauze,  which  retains  and  gives  off  the  carbolic  acid  for  a 
long  time,  is  placed  over  the  wound  to  create  an  antiseptic 
atmosphere. 

In  dressing  an  ordinary  flesh  wound  the  following  is  the  method 
to  be  pursued  : — Wash  around  the  wound  with  the  watery  solu- 
tion, and  apply  a  piece  of  protective  large  enough  to  overlap  the 
edges  of  the  wound ;  this  should  be  previously  dipped  in  the  solu- 
tion. Then  a  piece  of  gauze,  dipped  in  the  solution,  is  placed 
over  the  protective,  so  as  considerably  to  overlap  it.  Above  this 
six  or  eight  folds  of  loose  carbolized  gauze  are  laid,  and  lightly 
bandaged  with  a  gauze  bandage.  Lastly,  a  turn  of  elastic  bandage 
is  stretched  over  the  edges  of  the  dressing,  so  as  to  keep  it  in 
close  contact  \\ith  the  skin.  A  carbolic  spray  should  be  diffused 
over  the  wound  and  the  dressings  during  the  whole  process ;  and 
the  operator's  hands  should  be  kept  moist  with  the  solution. 

Let  us  now  suppose  that  a  lumbar  abscess  is  to  be  opened  upon 
Lister's  principle.  The  skin  around  the  point  of  pui^ture  and 
the  knife  are  smeared  with  carbolic  oil,  and  a  large  piece  of  lint 
saturated  with  the  same  is  held  over  it.  The  abscess  is  freely 
opened,  the  veil  of  lint  is  dropped  over  the  incision,  and  the  con- 
tents  of  the  cavity  are  gently  pressed  out,  the  discharge  oozing 
from  underneath  the  carbolized  veil.  Or  the  whole  operation  may 
be  performed  in  an  antiseptic  atmosphere  created  by  a  cloud  of 
spray  from  Richardson's  apparatus,  or  from  Lister's  "  spray- 
producer."  Over  the  incision  are  then  placed  a  few  folds  of 
antiseptic  gauze,  secured  by  a  bandage.  The  same  precautions 
must  be  observed  every  time  the  wound  is  dressed.  Putrefac- 
tion is  thus  prevented,  and  the  evils  that  it  carries  with  it  are 
avoided.  ANhen  the  wound  is  granulating  freely,  the  protective 
is  used  to  moderate  the  direct  action  of  the  carbolic  acid,  that 
the  atmosphere  of  the  wound  may  be  thoroughly  antiseptic, 
while  the  granulations  are  not  unduly  irritated.  The  freedom 
from  all  offensive  smells,  and  the  fact  that  the  protective 
(which  contains  a  small  quantity  of  litharge),  keeps  its  normal 
colour,  and  is  not  blackened  by  the  escape  of  sulphuretted 
hydrogen,  give  proof  of  the  absence  of  putrefaction.  Prac- 
tically this  last  is  a  very  delicate  and  useful  test,  for  as  soon  as 
decomposition  ■  comiuences  in  the  albuminous  discharges  a  black 
sulphuret  of  lead  is  formed  on  the  protective.  Even  when,  in 
spite  of  all  our  efforts,  suppuration  takes  place  in  a  wound,  the 
antiseptic  treatment  should  not  be  abandoned,  for  there  is  a  wide 
difference  to  the  patient  whether  the  pus  which  is  lying  in  con- 
tact with  a  raw  surface  is  or  is  not  in  a  state  of  putrefaction. 

The  "  germ  theory,"  upon  which  Lister's  method  rests,  must 
still,  I  think,  be  couddered  sub  judice.     That  the  irritation  which 


16  SURGICAL  DISEASES. 

the  air  undoubtedly  causes  in  a  wound  is  due  to  the  organic  par- 
ticles vvhicli  it  contains,  and  not  to  its  chemical  or  physical 
qualities,  seems  to  me  a  proposition  which  is  "not  proven." 
Still  there  can  be  no  question  of  the  value  of  carbolic  acid,  what- 
ever may  be  its  modus  operandi,  and  of  the  credit  which  is  due 
to  Lister  for  having  introduced  it  into  practice. 

When  it  is  used  as  a  simple  lotion  (F.  12),  or  when  dressings  are 
kept  constantly  moist  with  it  by  droppings  from  a  syphon  bottle, 
its  beneficial  effect  is  beyond  a  doubt ;  but  it  should  be  borne  in 
mind  that  this  is  not  Lister's  method,  and  that  cases  thus  treated 
should  not  be  classed  with  those  in  which  all  the  details  recom- 
mended by  him  have  been  thoroughly  carried  out.  In  the  treatment 
of  abscesses  Callender  has  recommended  that  they  should  be 
opened  and  injected  with  a  solution  of  carbolic  acid  (1  part  in  20), 
until  they  are  hyper-distended.  By  this  means  the  antiseptic 
wash  is  brought  into  contact  with  every  part  of  the  interior  surface. 

Carbolic  acid  is  not  the  only  substance  which  has  been  used  to 
check  suppuration.  Mr.  Campbell  De  Morgan  introduced  a 
strong  solution  of  chloride  of  zinc  (40  grains  to  the  ^j)  to  sponge 
out  wounds  immediatel}'^  after  operation;  and  a  weaker  solution 
(F.  27)  may  be  used  in  subsequent  dressings.  Sulphurous  acid 
lotion  (F.  14)  may  be  employed  with  great  benefit  for  the  same 
purpose. 

The  constitutional  treatment  of  suppuration  consists  in  sup- 
porting and  improving  the  patient's  health.  This  may  best  be 
done  by  placing  him  in  the  most  favourable  hygienic  conditions, 
ordering  a  light  and  nutritious  diet,  and  such  medicines  as  the 
mineral  acids,  steel,  cod-liver  oil,  and  quinine. 

VXiCERATZOXr. 

Ulceration  is  commonly  described  as  the  "  molecular  death" 
of  a  part;  and  this  destructive  action  may  either  occur  where 
the  surface  is  already  broken,  or  it  may  itself  give  rise  to  a  solu- 
tion of  continuity.  The  essential  nature  of  ulceration  is  involved 
in  some  obscTirity.  We  may,  however,  divide  the  process  into 
two  stages — (1)  That  in  which  the  tissues  are  broken  down  and 
disintegrated;  (2)  That  in  which  the  debris  is  re*ioved  or  dis- 
charged. 

The  first  stage,  that  of  disintegration,  seems  to  arise  either 
from  simple  arrest,  or  from  an  impairment  of  nutrition. 

When  the  supply  of  blood  to  a  part  is  cut  off,  ulceration  is  apt 
to  follow,  from  simple  arrest  of  nutrition.  There  are  certain 
situations— ^the  al<B  nasi,  for  example — where  the  circulation  is 
naturally  feeble,  which  are  specially  prOne  to  this  form  of  disease. 


MOKTIFICATION.  17 

But  an  impaired  or  faulty  nutrition  is  a  far  more  common 
cause  of  ulceration.  These  unfavourable  changes  in  the  nutrition 
of  the  part  are  generally  brought  about  by  inflammation.  Some- 
times they  follow  directly  upon  an  acute  attack  ;  sometimes  they 
result  from  the  alterations  of  texture — the  hardening  or  the  soft- 
ening— which  are  left  behind  after  the  acute  symptoms  have  sub- 
sided. In  these  two  ways  inflammation  is  a  frequent  source  of 
ulceration,  though,  as  we  have  said,  ulceration  may  occur  without 
inflammation. 

Whatever  lowers  the  vital  power,  either  of  the  part  or  of  the 
constitution  generally,  predisposes  to  ulceration — for  example, 
advancing  age,  broken  health,  loss  of  nerve  force,  chronic  con- 
gestion, a  strumous  or  syphilitic  taint,  and  many  other  con- 
ditions. 

The  most  common  exciting  causes  of  ulceration  are  acute  in- 
flammation, mechanical  injuries,  chemical  irritants,  and  con- 
tinuous pressure. 

The  second  stage  of  ulceration  is  that  in  which  the  debris  is 
removed.  Such  removal  may  take  place  either  outwardly  or  in- 
wardly. The  disintegrated  tissue  is  in  the  great  majority  of  cases 
thrown  off  from  the  ulcerating  surface  in  a  purulent  discharge, 
but  it  may  also  be  absorbed  by  the  lymphatics  and  veins.  This 
"  ulcerative  absorption "  is,  however,  comparatively  rare.  The 
purulent  discharge  is  sometimes  gritty  from  the  presence  of  minute 
particles  of  solid  matter.  This  is  specially  the  case  when  bone  is 
involved. 

Treatment. — The  local  treatment  consists  in  studying  the 
position  of  the  part,  allaying  inflammation  by  the  means  that 
have  been  already  mentioned,  and  endeavouring  to  mitigate  the 
ulceration  or  to  improve  its  character.  This  may  be  done  by  the 
use  of  sedative,  anodyne,  astringent  or  stimulating  applications. 
In  some  cases  the  ulcerating  surface  may  be  destroyed  by  a  strong 
caustic.  This  mode  of  treatment  is  particularly  applicable  to 
specific  and  unhealthy  sores. 

The  constitutional  treatment  is  of  the  utmost  importance. 
The  patient  should  be  placed  in  a  puj-e.and  fresh  air.  His  diet 
and  manner  of  life  should  be  regulated  ;  while,  at  the  same  time, 
his  general  health  may  be  improved  by  tonic,  anti-syphilitic,  or 
anti-scorbutic  medicines. 

nXORTIFXCATZOir. 

Mortification  signifies  the  death  of  a  part.  The  process  of 
dying  is  by  some  called  gangrene,  and  the  state  of  complete  death 
sphacelus.     By   others   these  terms   are    used   as   synonymous. 

c 


18  SURGICAL  DISEASES. 

When  a  limited  portion  of  tissue  dies,  it  is  said  to  slough ;  but 
the  changes  which  take  place  in  sloughing  and  mortification  are 
much  the  same,  the  only  difference  is  in  extent.  Indeed,  ulcera- 
tion, sloughing,  and  mortification  may  be  taken  to  be  ascending 
degrees  of  the  same  morbid  process. 

Gangrene  is  divided  into  moist  and  dry.  The  former  generally 
depends  upon  venous  obstruction,  and  is  usually  accompanied  by 
inflammation.  The  latter  may  exist  without  inflammation.  Its 
most  frequent  cause  is  a  deficient  supply  of  blood ;  and  this  de- 
ficiency may  arise  either  from  disease  or  from  injury — e.g.,  from 
senile  changes  or  from  crushing  violence.  This  leads  us  to 
another  distinction,  which  it  is  very  important  to  bear  in  mind — 
namely,  that  a  part  may  perish  either  from  constitutional  or  from 
local  causes. 

When  a  part  is  about  to  die  it  becomes  of  a  dusky  red  or 
purple  colour,  and  frequently  presents  a  mottled  appearance.  It 
becomes  doughy,  and  easily  breaks  down  under  pressure.  The 
temperature  falls,  and  there  is  loss  of  sensibility.  There  is  dull, 
heavy  pain,  occasionally  rising  into  acute  paroxysms.  The  cuticle 
is  raised  into  bullse,  and  an  evolution  of  gas  takes  place.  These 
symptoms  are  more  marked  in  moist  gangrene,  attended  by  a 
high  dpgree  of  inflammation,  than  in  the  dry  variety.  In  the 
latter  the  part  simply  withers — becomes  mummified. 

These  local  symptoms  are  always  accompanied  by  great 
exhaustion,  and  by  a  tendency  to  the  typhoid  forms  of  inflamma- 
tory fever. 

The  principal  causes  of  gangrene  are — (1)  external  injuries,  (2) 
an  arrest  in,  or  a  deficiency  of,  the  blood-supply,  (3)  obstruction 
to  the  venous  circulation,  (4)  specific  poisons,  as  in  the  cases  of 
cancrum  oris,  malignant  pustule,  or  sloujjhing  phagedsena. 

Under  the  first  head  fall  accidents  attended  by  severe  contu- 
sion and  laceration. 

Under  the  second,  ligatures  of  the  main  arteries,  embolisms 
and  cases  of  deficient  blood-supply'  from  weakness  of  the  heart, 
exhaustion,  or  narrowing  of  the  arterial  channels.  Fig.  2  repre- 
sents a  case  of  gangrene  in  an  infant  eleven  months  old  who 
was  under  my  care.  The  little  patient  was  recovering  from 
an  attack  of  measles  wlieu  the  left  foot  became  black,  hard, 
and  dry ;  and  on  the  thirty -second  day  dropped  ofi"  at  the  ankle- 
joint,  leaving  the  ends  of  the  tibia  and  fibula  protruding.  A 
proper  stump  was  then  formed,  and  the  child  made  an  excellent 
recover}'.     (Path.  Soc.  Trans,  vol.  xx.) 

But  how  is  the  spread  of  this  destructive  process  limited  ?  If 
the  gangrene  depends  upon  a  simple  arrest  of  the  circulation — 
e.g.t  on  plugging  or  deligation  of  the  main  artery — then  the  seat 


MOETIFICATION.  19 

of  such  obstruction  will  determine  the  point  where  the  disease 
ceases.  A  red  line  of  healthy  inflammation — the  line  of  demar- 
cation— will  indicate  the  separation  between  the  living  and  the 
dying  tissues. 

Fig  2.  ^^ 


Gangrene  of  the  foot  in  an  infant. 

If,  however,  the  gangrene  arises  from  inflammation,  it  may 
continue  to  spread  until  it  reaches  a  point  where  the  vitality 
of  the  tissues  resists  its  action.  They  are  in  a  more  healthy  state, 
and  the  inflammation  which  they  exhibit  is  of  a  more  healthy  kind 
also.  Instead  of  being  killed  by  the  intensity  of  the  inflammation, 
they  are  able  to  throw  out  lymph,  which  forms  a  barrier  to  its 
further  progress.  The  gangrenous  inflammation  is  then  changed 
into  the  adhesive. 

The  same  happy  result  occurs  when  the  inflammatory  action 
subsides  to  a  degree  which  is  compatible  with  the  efiusion  of  lymph. 

When  a  line  of  demarcation  has  been  formed,  a  process  of 
ulceration  immediately  begins,  by  which  the  mortified  part  is 
separated  and  thrown  off. 

Treatment. — In  the  early  stage  of  a  traumatic  gangrene  in  a 
robust  adult,  attended  by  much  inflammation,  we  may  have 
recourse  to  the  local  abstraction  of  blood.  Nature  herself  indicates 
this,  for  we  sometimes  see  great  benefit  follow  spontaneous  hse- 
morrhage.  By  taking  blood  from  the  part  tension  may  be  relieved, 
the  circulation  freed,  and  the  spread  of  the  gangrene  arrested. 

Incisions — either  a  number  of  small,  or  a  few  larger  ones — 
may  often  be  made  in  the  affected  part  with  advantage.  They 
not  only  relieve  the  over-stretched  tissues,  but  they  may  also 
give  vent  to  the  materies  morbi,  as,  for  example,  in  extravasation 
of  urine. 

At  the  same  time  the  other  local  means  for  allaying  inflam- 
mation, which  have  already  been  mentioned,  should  not  be 
omitted. 

The  separation  of  sloughs  should  be  promoted  by  poultices,  and 
the  unpleasant  smell  may  be  overcome  by  disinfectant  lotions,  or 
by  charcoal  or  yeast  mixed  with  the  poultices. 

o2 


20  SURGICAL  DISEASES. 

The  denser  tissues,  as  tendons  and  bones,  may  be  divided  in 
order  to  hasten  the  process  of  separation ;  but  it  is  best  to  leave 
the  soft  parts  to  themselves. 

After  the  mortified  portion  has  been  removed,  the  exposed 
surface  should  be  treated  as  an  ordinary  sore  with  water  dressing, 
or  with  anodyne,  antiseptic,  or  stimulating  lotions,  as  the  case 
may  require. 

In  regulating  the  constitutional  treatment  we  must  bear  in 
mind  that  mortification  is  often  the  result  of  debility,  and  that 
the  gangrenous  inflammation  is  always  accompanied  by  fever  of 
the  asthenic  and  irritative  type.  Moreover,  the  separation  of  the 
dead  tissues  is  an  exhausting  process,  and  one  which  makes  great 
demands  on  the  vital  powers  of  the  patient.  Everything,  there- 
fore, which  has  a  lowering  tendency  must  be  strictly  avoided. 
The  air  of  the  sick  man's  room  should  be  kept  as  fresh  as  possible, 
his  diet  should  be  light  and  nourishing,  while  his  strength  is 
upheld  by  tonic  medicines  and  stimulants.  Sedatives  and  narco- 
tics will  here  be  found  of  the  greatest  service,  and  should  be 
given  freely. 

Senile  gangrene  is  that  variety  which  is  met  with  in  persons 
advanced  in  life,  and  which  depends  essentially  upon  degeneration 
of  the  coats  of  the  vessels.  A  calcareous  deposit  takes  place  in 
the  walls  of  the  arteries,  and  this  aff'ects  the  circulation  in  two 
ways  :  (1 )  by  diminishing  the  calibre  of  the  vessels,  and  (2)  by 
impairing  the  elasticity  of  their  coats. 

Senile  garigrene  generally  attacks  the  feet.  Beginning  in  the 
toes  it  spreads  gradually  to  a  greater  or  less  extent  over  the 
foot  and  leg.  The  local  inflammation  is  usually  slight,  and  con- 
fined to  the  margins  of  the  gangrenous  part.  The  tissues  at 
first  become  mottled,  of  a  bluish  or  purplish  colour,  and  the 
cuticle  is  detached  and  raised  in  blisters.  Gradually  the  part 
becomes  brown  or  black,  and  at  the  same  time  dry  and  withered. 
When  a  line  of  demarcation  has  been  formed,  the  dead  tissues  are 
separated  from  the  living  by  a  process  of  ulceration,  in  the  way 
that  has  been  described. 

Senile  gangrene  is  always  attended  by  great  exhaustion,  severe 
pain,  and  a  tendency  to  low  irritative  fever.  From  these  causes, 
combined  with  the  age  of  the  patients,  it  is  a  very  fatal  disease. 
Occasionally  the  mortifitd  part  is  thrown  off*  and  recovery  takes 
place,  but  such  a  fortunate  result  is  quite  exceptional. 

The  best  treatment  consists  in  enveloping  the  part  in  cotton- 
wool, so  as  to  maintain  a  high  and  equable  temperature.  If  need 
be,  a  disinfecting  lotion  may  be  applied.  At  the  same  time 
everything  should  be  done  to  support  the  patient,  to  husband 
his    strength,   and    to    quiet   his    nervous    system.      Alcoholic 


PROCESSES   OF  EEPAIE.  21 

stimulants  should  be  given  with  caution,  because  it  is  hazardous 
to  overstrain  the  diseased  vessels. 

Question  of  amputation. — A  question  often  arises  whether  we 
should  resort  to  amputation  in  gangrene,  and,  if  so,  at  what  period 
of  the  disease.  Upon  this  point  the  special  circumstances  of  each 
case  must  go  far  to  form  our  opinion.  The  general  rule,  how- 
ever, may  be  stated  thus  : — In  gangrene  resulting  from  a  local 
cause — as  au  accident,  ligature,  or  embolism — an  amputation  may 
be  undertaken  as  soon  as  the  discoloration  of  the  tissues  has 
indicated  the  extent  of  the  affected  part.  But  in  the  state  of 
spontaneous  gangrene  it  is  well  to  wait  for  a  decided  line  of  de- 
marcation, and  then  to  content  ourselves  with  dividing  the  hard 
tissues  and  shaping  the  stump,  ratlier  than  to  perform  a  complete 
amputation.  If  the  gangrene,  though  beginning  in  a  local  cause, 
shows  a  tendency  to  spread  indefinitely,  it  should  be  treated  as  a 
case  of  spontaneous  mortification,  and  no  operation  should  be 
undertaken  until  a  well-marked  line  of  demarcation  has  declared 
itself. 

PROCESSES    OF  REPAIR. 

We  may  here  conveniently  consider  the  processes  of  repair. 
They  are — 

(1)  Immediate  union. — This  only  occurs  in  slight  and  clean- 
cut  wounds.  When  the  oozing  of  blood  has  ceased,  and  the  sur- 
faces have  been  brought  into  accurate  apposition,  they  become 
directly  incorporated  with  one  another.  In  such  a  case  there  is 
no  inflammation  and  no  appreciable  uniting  medium. 

Even  if  a  small  part  of  the  body,  such  as  the  point  of  a  finger, 
is  entirely  cut  off,  the  surgeon  need  not  despair  of  union  taking 
place.  Though  we  have  no  Balsam  of  Fierabras — of  which  Don 
Quixote  says  he  had  the  receipt  in  his  head — and  cannot  promise 
that  if  a  man  were  cut  in  two,  stuck  neatly  together,  and  took 
two  draughts  of  the  Balsam,  he  would  immediately  become  whole 
and  sound  as  an  apple  (ch.  x.),  yet  many  cases  are  on  record  in 
which  a  small  portion,  after  having  been  completely  separated,  has 
been  replaced,  and  has  united  and  grown  as  if  it  had  only  been 
partially,  and  not  entirely,  removed. 

(2)  Z'nion  hy  adhesion — "union  by  the  first  intention" — can 
only  take  place  between  surfaces  which  are  in  apposition,  and  in 
persons  whose  general  health  is  pretty  good.  It  is  attended  with 
some  degree  of  inflammation,  enough  to  produce  a  layer  of  plastic 
material  between  the  opposed  surfaces.  By  this  means  they  are 
glued  together.  There  is  union  by  adhesion.  Gradually  the 
layer  of  lymph  becomes  organized  and  assimilated  to  the  adjacent 
tissues. 


22  SURGICAL  DISEASES. 

(3)  Healing  ly  seabhing  is  a  process  of  repair  which  takes 
place  on  free  surfaces.  Like  the  foregoing,  it  is  attended  with  a 
very  limited  amount  of  inflammation.  There  is  a  slight  effusion 
of  lymph,  which  protects  the  raw  surface  from  the  external  air, 
and  allows  healthy  nutrition  and  repair  to  b«  carried  on  beneath 
it.  We  sometimes  endeavour  to  bring  about  this  mode  of  heal- 
ing, and  to  imitate  the  action  of  Nature,  by  an  artificial  scab  of  lint 
saturated  with  Friar's  balsam  or  collodion. 

(4)  Granulation — "  union  by  the  second  intention."  When 
the  destructive  processes,  ulceration,  suppuration,  and  gangrene 
have  terminated.  Nature  immediately  begins  to  repair  the  damage 
that  has  been  done.  The  raw  and  exposed  surface  is  covered 
with  a  layer  of  plastic  material — coagulable  lymph ;  beneath 
this,  and  in  its  substance,  granulations  spring  up — small  elevated 
papillae,  closely  studded  together,  of  a  bright  florid  colour,  and 
bathed  in  healthy  pus.  They  are  freely  supplied  with  blood  by 
loops  and  arches  from  the  subjacent  vessels,  but  their  sensibility 
is  generally  low.  These  are  the  characters  of  healthy  granula- 
tions. But  they  vary  exceedingly.  Sometimes  they  are  irregular 
and  exuberant ;  sometimes  they  are  pale  and  flabby ;  at  other 
times  they  have  a  dusky  and  congested  appearance;  or,  again, 
they  may  secrete  a  thin  and  acrid  discharge. 

When  two  granulating  surfaces,  as  the  sides  of  a  wound, 
are  brought  into  apposition,  adhesion  may  take  place  between 
them. 

(5)  When  the  granulations  have  risen  to  the  level  of  the 
surrounding  tissues  cicatrization  commences.  The  margins  of  the 
granulating  surface  cease  to  secrete  pus,  and  become  smooth  and 
varnished  over  with  a  thin  bluish-white  layer,  which  is  the  first 
indication  of  the  new  skin.  This  process  of  healing  spreads  from 
the  edges,  or  from  any  islands  of  skin  that  may  have  been  left, 
or  tltat  may  have  been  grafted  by  the  surgeon.  It  never  seems  to 
begin  in  the  centre  of  the  raw  surface.  As  it  goes  on,  it  draws 
the  margins  together  by  concentric  contraction. 

After  the  whole  has  been  skinned  over,  other  important 
changes  are  gradually  developed.  The  cicatricial  tissue,  which 
was  at  first  thin,  blue,  and  shining,  becomes  thicker,  of  a  natural 
colour,  and  covered  by  a  layer  of  epithelium  ;  in  fact,  it  ap- 
proaches, though  it  never  attains,  the  character  of  true  skin. 
Again,  after  a  cicatrix  is  fully  formed  it  continues  to  contract. 
This  contraction  may  go  on  for  months  or  years,  and  give  rise 
to  some  of  the  most  dreadful  disfigurements  and  inconveniences 
that  are  met  with  in  surgical  practice — as,  for  example,  in  the 
case  of  a  severe  burn. 


23 


BZil.X.FORIVIilTZOirS. 

The  cases  of  congenital  malformation  may  be  divided  into  two 
classes : — 

1 .  Those  in  which  there  is  an  arrest  of  development,  as  spina 

bifida,  harelip,  cleft  palate,  imperforate  anus,  &c. 

2.  Those  in  which  there  is  an  excess  of  development,  as  super- 

numerary fingers  and  toes,  &c. 

Of  the  causes  of  such  malformations,  our  present  knowledge 
enables  us  to  offer  no  explanation. 

Intra-uterine  disease  often  gives  rise  to  deformities.  Thus, 
the  foetus  may  meet  with  a  fracture  or  a  dislocation,  or  it  may  be 
born  with  club-feet.  One  of  its  limbs  may  even  be  caught  in  a 
noose  of  the  cord,  and  spontaneously  amputated. 

HYPHRTROPKir 

means  an  increase  in  the  size  of  a  part  from  over-development  of  its 
normal  and  healthy  structure.  It  is  sometimes  congenital,  but 
generally  it  is  the  result  of  increased  use,  and  in  many  cases  it  is 
a  provision  of  Nature  to  meet  the  exigences  of  disease.  As  ex- 
amples I  may  mention  the  congenital  hypertrophy  of  the  tongue 
that  is  sometimes  seen  in  infants ;  the  increase  which  takes  place 
in  the  muscular  coat  of  the  bladder  in  long-standing  cases  of 
stricture ;  or  the  development  which  one  kidney  undergoes  when 
the  other  is  unable  to  perform  its  functions. 

ATROPHir, 

on  the  other  hand,  means  the  decrease  which  takes  place  in  a 
part  from  wasting  of  the  proper  tissue,  or  from  its  deficient 
deposit.  It  depends  upon  a  variety  of  causes,  want  of  use,  excessive 
use,  impaired  vitality,  a  diminution  of  the  muscular  or  nervous 
supply,  &c.  I  know  a  lad  whose  right  leg  and  foot  are  atrophied, 
and  who  has  a  large  patch  of  white  hair  on  the  top  of  his  head — 
both  apparently  depending  upon  a  want  of  proper  innervation. 

Atrophy  is  very  often  accompanied  by  degeneration.  The 
proper  tissue  is  not  formed  at  all,  or  is  formed  in  deficient  quantity; 
while  its  place  is  occupied  by  fibrous,  earthy,  or  fatty  material. 
Of  these  degenerations  the  most  common  is  the  fatty.  Indeed, 
there  is  hardly  a  tissue  in  the  body  which  is  not  liable  to  be 
affected  by  it. 

TUmOlTRS. 

By  a  tumour  is  meant  a  living  mass,  which  is  either  different 
in   character  from  the  healthy   tissues  or  else  excessive  in  its 


24  SUEGICAL  DISEASES. 

growth.  A  cancer  diifers  from  every  other  tissue  which  is  met 
with  in  the  body,  not  so  much  in  its  histological  elements,  as  in 
their  arrangement.  A  fatty  tumour  is  merely  excessive  in  its 
growth  ;  the  material  of  which  it  is  composed  is  identical  with 
the  ordinary  adipose  tissue. 

Tumours  have  long  been  divided  into  two  great  classes — the  non- 
malignant  (innocent,  benign),  and  the  malignant  or  cancerous.  To 
these  it  has  been  found  necessary  to  add  a  third  class,  the  semi- 
malignant  or  recurrent.  This  is  not  perhaps  a  very  scientific 
classification,  but  it  is  one  of  great  practical  value. 

The  non-malignant  or  innocent  tumours  may  be  regarded  as 
being  from  first  to  last  local  diseases.  They  may  often  be  traced 
to  purely  local  causes.  When  they  are  solid,  their  structure 
resembles  some  one  of  the  normal  tissues  of  the  body — they  are 
homologous.  Moreover,  they  only  grow  in  situations  where  such 
tissue  is  naturally  found.  They  do  not  invade  the  adjacent  struc- 
tures. They  do  not  aficct  the  general  health,  unless  it  be 
accidentally,  from  their  size  or  position ;  and  when  they  are  once 
thoroughly  removed,  they  show  no  tendency  to  return.  Such 
are  the  marks  of  a  typical  non-malignant  tumour. 

The  malignant  growths,  on  the  other  hand,  present  a  complete 
contrast  in  all  these  pai'ticulars.  They  seem  to  depend  in  some 
degree  upon  a  constitutional  taint  or  an  hereditary  predisposition  ; 
though  some  local  imperfection — a  cicatrix,  a  wart,  a  mole — often 
serves  as  their  starting  point.  They  are  unlike  anything  that  is 
found  among  healthy  structures — they  are  heterologous.  They 
penetrate  the  neighbouring  tissues.  Thej'  impair  the  general 
health.  They  have  a  tendency  to  reproduce  themselves  in  various 
parts  of  the  body,  as  well  as  to  return  after  removal. 

But  between  these  two  extremes  there  is  an  intermediate  class, 
the  cancroid,  semi-malignant,  or  recurrent  tumours.  This  class 
comprises  growths  which  in  their  earlier  stages  resemble  the 
benign,  but  in  their  later  history  present  many  of  the  characters 
of  malignancy. 

The  benign  and  malignant  tumours  are  not  separated  by  any 
well-marked  line.  The  two  groups  shade  ofi"  into  one  another. 
That  infinite  variety,  which  we  observe  in  every  department  of 
disease,  supplies  links  which  unite  the  two  extreme  points  of  the 
chain. 

EHrCYSTED    TUMOURS 

are  met  with  under  two  forms — (1)  Those  which  consist  in  the 
distention  and  hypertrophy  of  natural  cysts  or  ducts ;  and  (2) 
those  which  result  from  the  enlargement  of  a  primitive  cell  or 
of  an  areolar  interspace. 


ENCYSTED  TUMOURS. 


25 


1.  To  the  first  class  belong  the  atheromatous  tumours,  which 
are  so  frequently  met  with  about  the  scalp,  face,  and  other  parts, 
as  the  result  of  obstruction  to  the  ducts  of  the  sebaceous  glands. 
They  are  situate  in  the  skin,  or  subcutaneous  cellular  tissue. 
They  are  rounded  and  smooth  in  their  outline.  Their  growth  is 
unattended  by  inflammation,  and  they  are  free  from  pain.  They 
are  often  found  in  great  numbers  in  the  same  individual.  They 
vary  from  the  size  of  a  pea  to  that  of  an  orange.  A  few  years 
ago  I  related  to  the  Pathological  Society  (see  Trans,  vol.  xx.)  a 
case  in  which  a  tumour  of  this  kind,  as  large  as  a  walnut,  was 
met  with  in  rather  an  unusual  situation — on  the  free  border  of 
the   prepuce.     Fig.    3    was   made   from   the   contents    of    this 

Fie:.  3. 


Contents  of  a  sebaceous  cyst. 

cyst.  As  these  tumours  grow  larger  they  are  apt  to  soften  and 
ulcerate.  But  more  frequently  they  are  removed  before  suppu- 
ration has  commenced.  The  cyst  may  be  dissected  out  unopened, 
or  an  incision  may  be  made  through  it,  its  contents  squeezed  out, 
and  then  the  cyst  itself  either  torn  or  dissected  away.  This 
should  be  done  carefully,  so  as  to  leave  none  of  it  behind.  When 
there  is  reason  to  avoid  a  cutting  operation,  the  c^'^st  may  be 
punctured,  its  contents  squeezed  out,  and  the  cavity  stirred  with 
the  point  of  a  probe ;    or  a  seton  may  be  passed  through  it. 

The  material  with  which  these  cysts  are  rilled  has  usually  a  fawn 
colour,  and  a  pasty  or  putty -like  consistence.  Sometimes  it  has 
a  very  offensive  smell.  It  is  made  up  of  the  sebaceous  secretion, 
epithelial  scales,  oil  globules,  granular  matter  and  crystals 
of  cholesterine. 

If  the  cyst  is  allowed  to  soften  and  ulcerate,  it  may  give  rise 
to  a  very  unhealthy  sore.     The  edges  become  everted  ;  there  is 


26 


SUEGICAL  DISEASES. 


a  thin  and  offensive  discharge ;  coarse  granulations  spring  up,  and 
an  intractable  ulcer  is  established,  having  some  of  the  characters 
of  malignancy. 

When  a  tumour  of  this  kind  ulcerates  and  breaks,  some  of  the 
contents  escape,  dry,  and  form  a  hard  scab.  If  this  is  allowed  to 
remain  it  gradually  becomes  more  and  more  prominent,  by  the 
escape  of  fresh  portions  of  the  contained  secretion,  and  thus  in 
process  of  time  "  a  horn  "  is  formed.     Such  horns  may  be  met 

with  on  any  part  of  the  body, 


Fig.  4. 


Horny  tumour  on  the  lower 
eyelid. 


and  sometimes  they  acquire  an 
extraordinary  length  and  de- 
velopment. Fig.  4  represents 
such  a  tumour,  which  occurred 
in  an  old  man  who  was  Mr. 
Bowman's  patient  at  the 
Royal  Ophthalmic  Hospital 
when  I  was  his  clinical  assis- 
tant. 

To  the  same  class  of  en- 
cysted tumours  belong  the  di- 
latations which  arise  from  ob- 
struction of  the  duct  of  the 
parotid  gland,  or  of  the  lacti- 
ferous ducts  of  the  mamma. 
In  all  cases  of  this  kind  the 
principle  of  treatment  is  simple 
enough.  It  consists  in  re- 
establishing the  natural  pas- 
sage.      But    in    practice    this 


is  sometimes  no  easy  matter,  and  requires  much  patience  and 
ingenuity  on  the  part  of  the  surgeon.  The  various  affections  that 
have  been  alluded  to  will  be  described  hereafter,  when  we  speak 
of  the  glands  with  which  they  are  connected. 

Again,  to  the  same  class  belong  the  swellings  which  are  formed 
by  the  distention  of  closed  cysts.  The  bursse,  when  they  are 
dilated,  afford  the  best  example  of  encysted  tumoi\rs  of  this  kind. 
The  effusions  into  the  sheaths  of  tendons  and  muscles  may  be  re- 
garded in  the  same  light.  In  these  cases  the  cyst  is  originally  of 
no  more  than  natural  thickness,  but  gradually,  as  the  disease  per- 
sists, it  becomes  tough,  and  dense,  and  fibrous.  The  fluid  contained 
in  these  cysts  is  sometimes  thick  and  glairy,  sometimes  thin  and 
serous.  Not  unfrequently  fibrinous  bodies,  like  melon  seeds,  are 
found  mixed  with  the  fluid,  or  attached  to  the  sides  of  the  cavity. 

In  treating  these  cysts,  we  endeavour  to  produce  absorption 
of  the  fluid  by  stimulating  applications.    If  this  fails,  we  may  tap 


SOLID  TUMOUES.  27 

the  cyst  simply ;  or  we  may  tap  it  and  scrape  the  internal  sur- 
face, or  inject  a  stimulating  fluid  ;  or  we  may  introduce  a  seton  ; 
or,  lastly,  we  may  dissect  the  cyst  out.  A  pedunculated  tumour 
of  this  kind,  as  large  as  a  walnut,  situated  over  the  sternum  in  a 
man  who  was  a  shoemaker  hy  trade,  I  removed  without  pain  by 
merely  slipping  a  small  elastic  band  over  it,  and  thus  constricting 
its  base. 

2.  The  second  class  of  encysted  tumours  includes  those  which 
may  be  considered  new  formations,  originating  in  the  enlargement 
of  a  primitive  cell,  or  an  areolar  interspace.  These  cysts  vary 
much  in  size.  Sometimes  they  attain  a  great  magnitude.  They 
are  filled  with  fluid  secreted  from  their  lining  membrane.  The 
character  of  this  fluid  varies  considerably.  Sometimes  it  is 
thin  and  serous  ;  at  other  times  it  is  thick  and  viscid.  Some- 
times it  is  straw-coloured  ;  at  other  times  it  is  dark  brown  or 
green. 

These  cysts  are  sometimes  simple — that  is  to  say,  composed 
of  only  a  single  cavity.  At  other  times  they  are  compound — the 
primary  cyst  containing  within  it  other  secondary  ones,  or  solid 
masses  of  fibro-plastic  material,  or  of  cancer.  In  some  rare  and 
curious  cases  they  have  been  found  to  enclose  teeth,  hair,  &c. 
Compound  cysts  are  generally  met  with  about  the  uterus,  broad 
ligament,  or  ovary. 

The  treatment  of  simple  cysts  should  be  conducted  on  the  plan 
already  laid  down.  We  may  first  try  to  promote  absorption 
of  their  contents.  If  this  fails,  we  may  puncture  them,  and 
endeavour  by  various  means  to  excite  inflammation  within  them. 
Or,  as  a  last  resource,  we  may,  if  circumstances  permit,  remove 
them  with  the  knife. 

The  treatment  of  compound  cysts  is  a  much  more  difficult 
matter.  We  can  hardly  hope  to  effect  a  cure  by  any  means 
short  of  excision  ;  and  this  is  generally  such  a  formidable  opera- 
tion, that  it  should  not  be  undertaken  without  great  care  and 
forethought. 

Cysts  are  often  met  with  in  the  substance  of  other  tumours. 
In  such  cases  they  have  probably  the  same  origin  as  in  the  two 
varieties  that  we  have  described.  They  arise  either  from  dilata- 
tion of  existing  cavities  or  canals,  or  else  from  the  enlargement  of 
primitive  cells. 

SOIiIB  TUMOURS. 

The  simplest  form  of  solid  tumours  that  we  meet  with  are  warts. 
They  are  formed  by  excessive  growth  of  the  papillae  of  the  skin, 
with  an  accumulation  of  epithelial  scales.  When  they  are  situated 
on  the  exposed  parts  of  the  body  they  are  hard  and  dry ;  when 


28  SURGICAL  DISEASES. 

they  grow  between  folds  of  skin,  where  the  perspiration  is 
retained,  they  are  soft  and  moist. 

Simple  warts  of  this  kind  are  often  seen  on  the  hands  of 
children  and  young  persons.  But  it  is  more  common  for  the 
surgeon  to  be  consulted  about  the  warts  {condylomata  acuta) 
which  are  often  seen  on  the  genital  organs  as  the  result  of 
gonorrhoeal  or  other  irritation  (see  Fig.  153),  or  about  the  mucous 
tubercles  (e.  lata)  which  are  apt  to  grow  near  the  verge  of  the 
anus,  the  vulva,  and  in  other  situations,  as  a  manifestation  of 
constitutional  syphilis. 

The  treatment  of  simple  warts  consists  in  burning  them  down 
with  caustics.  Gonorrhoeal  warts  should  be  cut  off  with  scissors, 
and  their  bases  touched  with  nitrate  of  silver.  Mucous  tubercles 
should  be  dusted  over  with  calomel,  or  smeared  with  a  calomel 
ointment  (F.  89),  or  moistened  with  black  wash. 

The  true  skin  sometimes  becomes  hypertrophied,  and  rises  into 
a  flat  tumour  of  a  reddish-brown  colour,  and  with  an  irregular 
outline.  Such  overgrowths  are  known  by  the  name  of  chelis,  or 
cheloid  tumours.  Sometimes  they  arise  spontaneously,  at  other 
times  they  appear  to  originate  in  local  irritation.  They  often 
commence  in  a  cicatrix,  especially  the  cicatrix  resulting  from  a 
burn.  Their  favourite  situation  is  the  chest,  but  they  may  show 
themselves  anywhere,  and  when  once  they  have  begun  to  grow 
they  may  spread  indefinitely.  They  cause  no  pain,  only  uneasiness 
and  disfigurement. 

No  remedies  appear  to  have  any  efiect  upon  them.  The  only 
treatment  that  holds  out  a  hope  is  excision;  and  even  after  com- 
plete removal  they  are  extremely  apt  to  return. 

poi.irpus. 

When  a  mucous  membrane  becomes  inflamed  and  thickened  it 
may  give  rise  to  polypus.  These  tumours  are  met  with  in  the 
nose,  the  pharynx,  the  uterus,  and  in  fact  in  almost  all  the 
mucous  surfaces.  Polypi  diff^er  widely  in  their  texture,  and  in 
the  nature  of  their  attachments.  The  gelatinous  polypus  con- 
sists of  an  expansion  of  the  normal  elements  of  the  mucous 
membrane.  Such  a  growth  as  this,  springing  from  a  narrow 
pedicle,  forms  the  simplest  kind  of  polypus.  But  sometimes 
fibrous  tissue  enters  more  or  less  into  the  composition  of  the 
tumour,  or  it  may  rise  from  a  broad  base,  adherent  perhaps  to 
bone.  When  these  conditions  are  present,  the  disease  assumes 
a  more  serious  aspect,  and  is  very  prone  to  degenerate  into 
medullary  cancer. 

The  treatment  consists  in  early  removal.  This  may  be  done  in 
various   ways,    according   to   the  nature   and    situation  of  the 


GLANDULAR  TUMOURS.  29 

tumour.  Sometimes  the  polypus-forceps  serve  our  purpose  tlie 
best;  sometimes  the  loop  of  the  ecraseur,  or  a  noose  of  ligature, 
is  the  most  convenient  appliance;  sometimes  we  must  have 
recourse  to  the  knife,  the  gouge,  and  the  bone-forceps. 

GIiAITDUIiAR  TUMOURS. 

The  various  superficial  glands  often  become  hypertrophied. 
Such  hypertrophy  is  commonly  associated  with  changes  of  texture. 
The  lymphatic  glands  are  often  affected  in  this  way ;  so  are  the 
mamma?,  the  testes,  the  thyroid  body,  &c.  The  gland  becomes 
enlarged,  though  without  pain,  and  presents  a  tumour  which  is 
circumscribed,  smooth  or  lobulated  in  its  outline,  movable,  firm, 
and  often  elastic  to  the  touch.  Sometimes  it  is  callous,  at  other 
times  tender  on  pressure. 

Tumours  of  this  kind  may  often  be  attributed  to  chronic 
inflammation.  They  frequently  cause  great  inconvenience  by 
interfering  with  the  action  of  adjacent  organs  or  parts.  They 
almost  always  betoken  a  faulty  state  of  the  general  health,  and 
we  must  deal  with  them  accordingly. 

Treatment. — If  the  patient  is  of  a  strumous  habit,  we  must 
give  cod-liver  oil,  or  the  preparations  of  iron  or  of  arsenic ;  while 
iodine  tincture  or  ointment,  or  an  ointment  composed  of  equal 
parts  of  ung.  hyd.  and  ung.  iodi,  or  the  emp.  ammoniaci  c.  hyd., 
or  fly  blisters,  or  other  resolvent  remedies  are  applied.  The  nng. 
hyd.  iodidi  rubri  is  held  in  high  estimation  by  some  surgeons ; 
but  it  must  be  used  with  caution.  Some  of  the  natural  mineral 
waters — e.g.,  those  of  Woodhall  in  Lincolnshire,  and  Kreutznach 
in  Rhenish  Prussia — are  often  most  beneficial  in  this  class  of 
cases.  Chronic  enlargements  of  the  cervical  glands  are  common 
in  young  persons  of  a  strumous  constitution.  In  such  cases  the 
surgeon  should  be  on  the  alert  for  the  slightest  indications  of 
Inng  disease,  for  scrofulous  glands  are  often  the  forerunners  of 
scrofulous  pneumonia. 

If  the  enlargement  depends  upon  a  syphilitic  taint,  a  mercurial 
ointment  should  be  applied  to  the  part;  and  at  the  same  time 
the  preparations  of  mercury  or  the  iodide  of  potassium  should  be 
given  internally. 

When  all  otlier  remedies  have  been  found  ineffectual,  the  ques- 
tion of  excision  may  be  entertained.  I  have  seen  fifteen  enlarged 
glands  removed  from  the  right  axilla,  the  largest  was  as  big  as  a 
kidney.  The  patient  was  a  young  man,  and  the  disease  quite 
incapacitated  him  for  work. 


30 


SUEGICAL  DISEASES. 


THE    FATT7    TUMOUR  (liIPO»Cii) 

is  identical  in  structure  with  the  healthy  adipose  tissue.  It  is 
generally  found  in  those  situations  where  there  is  naturally  a 
good  deal  of  fat,  as  the  back  of  the  neck,  the  shoulders,  or  the 
buttocks.  Sometimes  it  has  a  broad  base;  sometimes  it  is 
pedunculated. 

It  consists  of  large  polygonal  fat-cells  crowded  together  in  the 
meshes  of  an  areolar  tissue.  Fig.  5,  as  well  as  several  of  the  other 
drawings  with  which  this  chapter  is  illustrated,  were  taken  from 
preparations  which  were  kindly  lent  me  by  Dr.  Mitchell  Bruce. 
The  lipoma  is  enclosed  in  a  fibrous  capsule,  from  which  it  receives 
its  supply  of  blood.  This  capsule  gives  off  septa  which  divide  it 
into  lobules.  It  is  generally  free  from  pain,  and  causes  incon- 
venience only  by  its  size  or  situation.  It  is  smooth  and  rounded 
in  shape.  It  feels  soft  and  doughy ;  but  sometimes,  when  the 
capsule  is  stretched,  it  is  elastic,  and  may  easily  be  mistaken  for  a 
fluid  tumour.  It  is  most  likely  to  occur  at  middle  age ;  and  it  is 
not  often  that  we  find  more  than  one  present  in  the  same  in- 
dividual. It  grows  slowly  but  steadily,  and  may  reach  an 
enormous  size. 

Fiff.  5. 


Lipoma,  traversed  by  a  small  vein,  x  300. 

Some  cases  are  on  record  in  which  tumours  of  this  kind  have 
been  observed  gradually  to  shift  their  position — for  example,  from 
the  groin  to  the  perineum,  or  from  the  shoulder  to  the  breast. 
As  such  movements  are  always  in  a  downward  direction,  it  is 
probable  that  they  are  caused  by  the  weight  of  the  tumour,  and 
are  due  to  the  force  of  gravitation. 

Treatment. —  Little  or  no  benefit  is  likely  to  result  from  inter- 
nal remedies,   though  the  iodide  of  potassium   and  the  liquor 


THE  NEUROMA. 


31 


potasssE  have  been  recommended.  Removal  with  the  knife  is  the 
proper  treatment.  An  incision  should  be  made  across  the  tumour, 
and  then  the  entire  mass,  capsule  and  all,  should  be  torn  from  its 
connexions,  or  separated  by  a  few  touches  of  the  scalpel.  If  this 
is  carefullv  done,  it  is  highly  improbable  that  there  will  be  any 
return  of  the  frrowth. 


Figr.  6. 


THE    FIBROUS    TUIVIOUR    (FIBROMA) 

is  developed  from  the  connective  tissue,  and  presents  the  varieties 
with  which  all  are  f;\uiiliar  in  that  structure.  Sometimes  it  is 
dense  and  compact,  like  tendon ;  at  other  times  it  is  looser  and 
more  separable.  The  fibres  are  sometimes  straight,  and  laid  side 
by  side  in  parallel  rows ;  at  other  times  they  are  wavy  and  inter- 
laced in  every  direction.  For  the  specimen  from  which  Fig.  6  was 
drawn  I  am  indebted  to  Dr.  T.  Henry  Green.  Like  the  normal 
fibrous  tissue,  these  tumours  are  very  sparingly  supplied  with  vessels. 
If  we  except  the  so-called  fibrous 
tumours  of  the  uterus  (which  are 
really  composed  in  great  part  of 
unstriped  muscular  tissue),  their 
most  frequent  seat  is  the  neck;  but 
they  also  grow  elsewhere — in  the 
breast,  or  attached  to  the  perios- 
teum in  various  situations.  They 
often  occupy  the  antrum,  and 
give  rise  to  great  disfigurement. 
They  are  hard  and  inelastic  to 
the  touch.  Their  outline  is 
smooth  and  lobular,  and  they  are 
usually  enclosed  in  a  capsule. 
They  grow  slowly,  and  are  attended  by  little  or  no  pain.  They 
may  attain  a  great  size.  They  belong  to  the  middle  and  later 
periods  of  life.  It  is  seldom  that  we  find  more  than  one  in  the 
same  subject. 

As  they  advance  they  may  degenerate  and  become  infiltrated 
with  earthy  salts;  or  cysts  may  be  developed  in  their  interior; 
or  they  may  infiame  atid  suppurate,  ulcerating  through  the  skin, 
and  giving  rise  to  a  foul  and  ofiensive  sore. 

THB    NHUHOTflA. 

is  a  tumour  connected  with  a  nerve  or  its  sheath.  The  substance 
of  it  is  fibrous.  In  shape  it  is  generally  rounded  or  oval,  and  it 
may  attain  the  size  of  a  cocoa-nut. 

It  is  commonly  multiple.     It  is  harmless  in  its  nature,  but  it 


Fibroma,  x  300. 


32  SURGICAL  DISEASES. 

gives  more  or  less  inconvenience  by  the  pressure  it  exerts  upon 
the  neighbouring  parts.  Sometimes  it  is  callous  and  free  from 
pain ;  in  other  cases  it  is  very  painful  and  sensitive  to  the  touch. 
Everything  seems  to  depend  upon  the  exact  relation  it  bears  to 
the  nerve  with  which  it  is  connected. 

Extirpation  is  the  only  treatment  that  is  likely  to  be  successful. 

The  painful  subcutaneous  tumour  must  be  distinguished  from 
the  foregoing.  It  is  generally  single,  and  it  gives  rise  to  exquisite 
pain,  though  it  does  not  appear  to  be  connected  with  any  nerve 
of  appreciable  size. 

These  tumours  should  be  excised  at  an  early  period  of  their 
growth,  for  they  are  not  amenable  to  any  milder  treatment.  As 
a  rule  they  are  not  liable  to  return. 

THE  SARCOniATii. 

The  group  of  new  formations  which  were  formerly  called 
Jihro-plastic,  fibro-cellular,  and Jlbro-nucleated,  and  which  consti- 
tute the  semi-malignant  or  recurrent  class  of  tumours,  are  now 
usually  spoken  of  as  sarcomata.  They  are  essentially  connective 
tissue  growths,  the  connective  tissue  undergoing  rapid  develop- 
ment, but  always  retaining  its  embryonic  structure,  and  never 
reaching  maturity.  They  are  all  made  up  chiefly  of  cells,  together 
with  a  small  but  variable  proportion  of  intercellular  substance, 
'  and  it  is  by  the  prevailing  character  of  their  cells  that  they  are 
usually  classified.  Thus  they  are  divided  into  (1)  spindle-celled 
sarcoma,  (2)  round-celled  sarcoma,  and  (3)  myeloid  sarcoma. 

1.  The  spindle-celled  sarcoma — the  fibro-plastic  tumour  of 
earlier  writers — bears  a  close  resemblance  to  the  fibroma. 
It  consists  of  fusiform  cells,  ranged  closely  together  in  parallel 
rows,  which  traverse  the  growth  in  various  directions.  In 
Fig.  7  they  have  been  fretted  out  so  as  to  bring  some  of  the 
individual  cells  more  clearly  into  view.  They  often  begin  in  the 
subcutaneous  cellular  tissue,  or  in  the  cellular  tissue  of  the 
mamma  and  lymphatic  glands.  Not  unfrequently  they  have  a 
deeper  origin,  and  spring  from  the  periosteum,  more  especially  of 
the  facial  bones.  They  grow  more  quickly  than  the  fibrous 
tumours,  and  are  attended  by  more  pain.  They  occur  chiefly 
about  middle  life,  and  are  usually  single.  They  may  attain  a 
very  large  size. 

2.  The  round-celled  sarcoma  is  softer  and  more  vascular  than 
the  preceding.  The  cells  are  small  and  round,  and  there  is  little 
or  no  intercellular  substance.  They  grow  rapidly,  and  extend  by 
invading  the  adjacent  connective  tissue.  This  sarcoma  bears  a 
general  resemblance  to  the  encephaloid  variety  of  cancer,  but  is 


THE  SARCOMATA. 


33 


distinguished  from  it  by  the  want  of  a  fibrous  stroma,  by  the 
uniformity  of  its  cells,  and  by  the  mode  of  its  extension  along  the 
lines  of  areolar  tissue. 

Fls.  7. 


Spindle-celled  sarcoma,  x  30O. 

3.  The  myeloid  sarcoma,  like  the  two  preceding  varieties,  con- 
sists of  embryonic  connective  tissue,  but  it  is  distinguished  by  the 
large  irreorular  mother-cells  which  it  contains.  These  cells  are 
merely  the  cells  of  the  medulla  (juveXoy,  the  spinal  marrow)  in  a 
state  of  excessive  activity.  And  this  fact  points  to  one  of  the 
peculiarities  of  the  myeloid  tumours — namely,  that  they  always 
originate  from  bone,  and  almost  alwaj's  from  a  medullary  cavity. 
Some  examples  of  epulis  belong  to  this  class ;  so  do  many  of  the 
tumours  that  we  see  connected  with  the  ends  of  long  bones. 
They  generally  have  a  capsule  derived  from  the  periosteum  of 
the  bone  from  which  they  spring.  They  are  sometimes  so  vascular 
as  to  pulsate  and  give  rise  to  an  aneurysmal  bruit.  If  they  are 
punctured,  they  bleed  freely. 

As  a  group  the  sarcomata  approach  in  some  of  their  characters 
to  the  cancers.  Thus  they  extend  along  the  planes  of  cellular 
tissue,  invading  the  adjacent  parts,  and  they  are  apt  to  recur 
after  removal,  as  well  as  to  reproduce  themselves  in  internal 
organs,  through  the  dissemination  which  takes  place  in  the 
blood.  They  are  the  new  formations  to  which  early  life  is 
most  subject,  and  they  are  very  fatal.  They  are  therefore 
malignant  diseases,  though  histologically  they  are  distinguished 
from  cancers.  Besides  the  difference  in  their  microscopical  charac- 
ters, they  are  contrasted  w^ith  the  cancers  by  not  infecting  the 
lymphatic  glands,  and  not  invading  other  tissues  than  the  areolar. 
The  softer  and  more  vascular  the  species  of  sarcoma  the  more 
rapid  will  be  its  local  development,  and  the  more  readily  will  it 
disseminate  itself  throughout  the  body  by  means  of  the  cir- 
culation. 

D 


34 


SUEGICAL  DISEASES. 


Speaking  generally,  the  sarcomata  have  a  smooth  rounded 
surface;  sometimes  they  are  hard  to  the  touch,  at  other  times 
elastic  ;  sometimes  they  have  a  uniform  consistence,  at  other  times 
the  same  tumour  presents  both  hard  portions  and  soft.  They 
often  grow  to  a  large  size.  If  the  skin  breaks,  they  may  ulcerate; 
and  the  patient  may  be  worn  out  by  an  exhausting  discharge,  by 
pain  and  by  discomfort.     Fig.  8  was  drawn  from  a  middle-aged 

woman    who    had 


Fig.  8. 


Eecurrent  fibroid  tumour. 


a  "recurrent  fib- 
roid" tumour  be- 
tween the  collar- 
bone and  the 
breast  on  the  left 
side.  Its  history 
extended  over  six- 
teen years,  and  it 
was  seven  times 
removed  by  opera- 
tion. At  the  time 
the  sketch  was 
made  it  measured 
twenty  -  seven 
inches  in  circum- 
ference, and  the 
mass  which  was 
removed  by  Sir  W. 
Fergusson  weighed 
almost  six  pounds. 
Ultimately  the 
patient  sank  at 
the  age  of  forty- 
three. 

No     treatment 


short  of  excision  is  of  any  avail ;  and  even  after  they  have 
been  removed,  these  tumours  are  extremely  apt  to  recur  again 
and  again.  In  operating  upon  them  the  surgeon  should  cut 
wide  of  their  apparent  circumference,  so  as  to  take  away  all 
the  areolar  tissue  that  may  be  in  the  least  degree  afi'ected, 
and  the  wound  should  be  washed  out  with  strong  chloride 
of  zinc  lotion  (F.  28). 


ENTCHOM-DROMA. 

The  cartilaginous  tumour  (enchondroma)  is,  in  its  simplest  form, 
almost  identical  with  foetal  cartilage.     On  section  it  presents  a 


BONY  TUMOUES. 


35 


hard  shining  surface,  of  a  bluish-white  colour.  Under  the 
microscope  it  is  seen  to  consist  of  a  stroma,  which  may  be  hyaline, 
granular,  or  slightly  fibrillated,  and  in  which  there  are  large 
round,  oval,  or  caudate  cells,  containing  nuclei  (Fig.  9). 

It  is  developed  from  con- 
nective tissue,  and  is  often 
associated  with  the  perio- 
steum, especially  of  the 
bones  of  the  hand ;  but  it 
may  also  occur  in  the 
soft  tissue  of  glands — for 
example,  in  the  parotid,  or 
in  the  testicle.  Its  outline 
is  smooth  and  nodulated. 
It  feels  firm  and  slightly 
elastic   to  the   touch.      It 


3UU. 


Enchondi'oma, 

often  appears  in  childhood  or  about  the  early  period  of  adult 
life,  and  it  is  no  uncommon  thing  to  see  several  tumours  growing 
near  one  another.  At  first  it  progresses  slowly,  and  is  unat- 
tended  with  pain.     But  if  it  is 


Fig.  10. 


'■^ 


:ik 


allowed  to  remain,  it  involves 
the  skin  and  ulcerates ;  and 
the  result  is  an  intractable  sore, 
which  has  something  of  a 
malignant  aspect. 

The  only  remedy  is  re- 
moval. If  circumstances  per- 
mit, the  tumour  should  be 
thoroughly  extirpated.  If  it 
is  attached  to  bone,  the  base 
must  be  freely  removed ;  and,  if 
need  be,  a  resection,  or  perhaps 
even  an  amputation,  will  have 
to  be  performed. 

Boxrv  TunxouRs. 

A  deposit  of  osseous  matter 
having  more  or  less  the  charac- 
ters of  true  bone,  sometimes 
takes  place  in  the  substance 
of  fibrous  or  sarcomatous 
tumours.  Such  a  growth  is 
usually  spoken  of  as  an  osteo-sarcoma.  Fig.  10,  taken  from  a 
preparation  in  the  maseum  of  Charing  Cross  Hospital,  shows 
the  bony  skeleton  of  such  a  tumour. 

D  2 


1  fHs 


ir^^ 


36  SURGICAL  DISEASES. 

Again,  an  enchondroma  sometimes  becomes  developed  into 
bone. 

But  it  is  more  common  to  meet  with  osseous  tumours  spring- 
ing directly  from  bone  (exostosis).  Such  growths  occur  under 
two  conditions — either  they  are  dense  in  texture,  like  ivory  ;  or 
they  are  composed  of  cancellated  tissue.  They  will  be  more 
fully  considered  hereafter  when  we  come  to  speak  of  the  diseases 
of  bones. 

THE   CANCERS— CARCZlUOniATA, 

We  come  now  to  that  group  of  malignant  diseases  which  is 
distinguished  by  the  name  Cancer  or  Carcinoma,  and  which 
includes  four  varieties — Scirrhous,  Encephaloid,  Epithelioma, 
and  Colloid. 

The  cancers  are  new  formations  of  an  epithelial  type,  and  con- 
sist of  cells,  compaeted  together  without  any  intercellular  substance 
and  lying  in  the  spaces  of  a  fibrous  stroma.  They  are  heterolo- 
gous— that  is  to  say,  the  elements  are  alien  to  the  situation  in 
which  they  are  found,  and  they  present  in  a  high  degree  the 
clinical  marks  of  malignancy — i,e.,  they  invade  the  surrounding 
structures,  they  impair  the  general  health,  they  are  apt  to  return 
after  removal,  and  they  give  rise  to  secondary  deposits  in  various 
parts  of  the  body.  Paget  says  they  are  hereditary  to  the  extent 
of  one  case  in  three. 

The  cells  that  are  met  with  in  cancers  vary  much,  for  they 
represent  all  the  varieties  of  epithelium,  both  when  it  is  fully  de- 
veloped and  while  it  is  in  process  of  formation.  But  if  the  tumour 
is  examined  at  a  spot  where  the  cells  are  fully  formed,  but  have 
not  yet  begun  to  undergo  retrogressive  changes,  it  will  be  found 
that  they  are  like  the  epithelium  of  the  part  in  which  the 
growth  originated.  Thus,  the  cells  may  be  large  or  small, 
regular  or  irregular  in  outline.  They  may  be  round,  or  oval, 
or  pyriform,  or  caudate — the  exact  shape  depending  much  upon 
the  degree  of  pressure  to  which  the  elements  of  the  growth  have 
been  subjected.  Some  are  simple;  others  are  compound,  and 
contain  two  or  three  complete  cells  within  them,  with  nuclei 
and  nucleoli.  When  degenerative  changes  have  commenced — 
and  such  changes  are  very  common  in  morbid  growths  of  this 
kind — the  cells  are  often  loaded  with  oil-globules  and  granular 
matter. 

All  the  cancers,  inasmuch  as  they  are  apt  to  affect  the  organs 
of  digestion  and  assimilation,  are  sometimes  attended  by  the 
leaden  hue,  the  emaciation,  and  the  deep  dejection  to  which  the 
old  writers  gave  the  name  of  the  "  cancerous  cachexia."  But 
in  truth  there  is  no  cachexia  peculiar  to  cancer.     Some  persons 


THE  CANCERS  — CARCINOMATA. 


37 


suffering  from  this  complaint  present  a  very  healthy  appearance ; 
while,  on  the  other  hand,  many  patients  affected  with  organic 
diseases  of  very  different  kinds  exhibit  in  a  marked  degree  the 
symptoms  to  which  I  have  alluded. 

Scirrhous  or  hard  cancer  is  a  disease  of  adulb  life.  It  occurs 
in  two  forms :  (1)  as  a  close  compact  mass ;  and  (2)  infiltrated 
through  the  substance  of  an  organ  or  tissue.  In  either  case  it 
gives  rise  to  a  rough,  irregular  tumour  of  almost  stony  hardness. 

It  is  three  times  more  common  in  women  than  in  men.  It 
often  attacks  the  uterus,  but  still  more  frequently  the  fsmale 
breast.  A  small  lump  is  detected,  perhaps  as  large  as  a  marble. 
Slowly,  but  surely,  it  increases  in  size ;  and  as  it  grows,  it  draws 
to  itself,  by  a  kind  of  concentric  contraction,  the  surrounding 
structures.  The  skin  becomes  puckered,  and  the  nipple  retracted. 
There  is  pain  of  a  shooting,  darting  character.  Still  the  tumour 
moves  freely  between  the  skin  and  the  subjacent  muscle. 
Presently  adhesions  are  formed.  In  front  the  skin  becomes  in- 
volved; while  behind  the  disease  attacks  the  pectoral  muscles. 
Enlarged  lymphatic  glands  may  be  felt  in  the  axilla,  which  are 
distinctly  connected  with  the  tumour  by  a  line  of  swollen 
absorbents.  Gradually  the  skin  covering  the  tumour  turns  to  a 
purple  or  bluish  colour,  breaks,  and  ulcerates.  An  unhealthy 
and  offensive  discharge  commences.  The  pain  becomes  more 
acute  and  more  constant.  The  patient's  general  health  begins 
to  suffer.  She  grows  sallow,  loses  flesh,  and  becomes  dispirited. 
Secondary  deposits  are  formed  in  other  parts  of  the  body,  very 
probably  in  the  lungs  or  liver  ;  and  she  at  length  sinks,  worn  out 
by  incessant  pain  and  pro- 
fuse discharge,  or  by  the 
damage  done  to  some  vital 
organ  (see  Fig.  122). 

The  secondary  cancer  is 
not  necessarily  of  the  same 
variety  as  the  primary 
disease  which  gave  rise  to 
it.  Thus,  scirrhus  of  the 
breast  may  lead  to  en- 
cephaloid  of  the  liver  or 
lungs.  The  same  general 
rule  holds  good  of  all 
cancers. 

If  a  section  is  made 
of  a  scirrhous  tumour,  it  is 
so  dense  and  tough  that  it 
creaks  as  the   knife  passes 


«t"^. 


Scirrhous  cancer,  x  300. 


38  SURGICAL  DISEASES. 

through  it,  and  the  cut  surfaces  present  a  white,  glistening, 
satiny  appearance,  intersected  hy  bands  of  fibrous  tissue.  If  a 
thin  section  is  examined  under  the  microscope,  it  presents  the 
appearances  depicted  in  Fig.  11 — an  abundant  fibrous  stroma 
containing  cells  of  an  epithelial  type.  If  the  cut  surface  of 
the  tumour  is  scraped,  the  fluid  thus  obtained — the  cancer-juice 
— will  be  found  to  contain  these  cells,  and  thus  far  will  furnish 
an  indication  of  the  nature  of  the  disease. 

The  encephaloid,  medullary,  or  soft  cancer  is  the  acutest  and 
most  malignant  variety  of  the  disease.  It  differs  from  the  fore- 
going chiefly  in  the  rapidity  of  its  growth,  and  the  scantiness 
of  its  fibrous  stroma.  It  is  met  with  in  many  situations  where 
scirrhus  is  unknown :  it  often  attains  an  enormous  size,  and 
sometimes  bleeds  freely. 

It  begins  as  a  soft,  smooth,  and  lobulated  tumour,  somewhat 
elastic  to  the  touch,  and  not  unlikely  to  be  mistaken  for  fluid. 
It  increases  apace,  making  its  way  towards  the  sui'face.  The 
skin  covering  it  is  marked  by  dilated  veins,  and  is  some- 
times even  oedematous.  When  it  has  reached  this  point, 
it  very  soon  involves  the  skin,  ulcerates,  and  bursts  forth 
in  the  form  of  large  fungoid  protrusions,  from  which 
there  escapes  an  offensive  discharge.     Fig.  12  was  taken  from  a 

Fig.  12. 


Encephaloid  cancer  in  the  forearm. 

young  woman,  aged  27.  The  tumour  had  been  growing  for 
two  years ;  and,  as  it  resisted  all  ordinary  treatment,  amputation 
was  recommended.  An  encephaloid  cancer  is  very  vascular,  and 
if  any  obstruction  to  the  return  of  blood  occurs,  either  from 
constriction  at  the  point  of  protrusion,  or  from  any  other  cause, 
bleeding  is  very  apt  to  take  place.  Such  appears  to  be  the 
pathology  of  that  variety  which  is  known  as  fungus  hcBmatodes, 
and  which  consists  of  nothing  but  the  soft,  spongy,  encepha- 
loid tissue,  surcharged  with  blood  (Fig.  13).  In  these  very 
vascular  tumours  pulsation  may  sometimes  be  felt,  and  a  bruit 


THE  CANCEES — CARCINOMATA. 


39 


detected  with  the  stethoscope.    This  has  heen  particularly  noticed 
when  the  disease  is  connected  with  bone. 

Encephaloid  cancer  may  occur 
at  any  age.  It  is  often  met 
with  in  young  children.  It 
may  show  itself  almost  any- 
where ;  but  its  favourite  seats 
are  the  orbit  (see  Fig.  112),  the 
nasal  cavities,  the  mamma,  the 
testicle,  the  bones,  and  the  vis- 
cera. 

To  the  naked  eye  it  has  the 
appearance  of  brain- substance.  It 
contains  an  abundance  of  the  can- 
cer juice,  and  but  little  fibrous 
tissue.  Under  the  microscope  its 
cells  are  found  to  be  irregular 
in  outline,  imperfectly  formed, 
and  loosely  arranged,  and  very 
prone  to  fatty  degeneration.  It 
disseminates  itself  rapidly,  and 
soon  leads  to  a  fatal  termination. 


Soft  cancer  surcharged  with 
blood. 


Fig.  14  represents  this  brain- 
like substance  growing  from  the  hand  after  the  third  finger  had 
been  already  removed  on  account  of  encephaloid  disease. 

The  third  variety 
of    cancer    is     that  -^^S*  ■^^* 

which  is  known  as 
epithelioma  or  ejoi- 
thelial  cancer.  Both 
histologically  and 
clinically  it  difiiers 
somewhat  from  the 
varieties  already  de- 
scribed; so  much  so 
that  somewritershave 
regarded  it  as  not 
being  of  a  cancerous 

nature.  But  when  it  shows  itself  in  a  soft  and  moist  tissue — 
e.ff.,  the  tongue — it  presents  all  the  clinical  features  of  the  most 
malignant  cancers;  and  when  it  occurs  on  external  parts  it  can 
only,  at  the  best,  be  regarded  as  rather  a  milder  and  more 
chronic  form  of  the  disease. 

Histologically  it  is  distinguished  by  the  fact  that  it  almost  always 
originates  in  a  mucous  or  cutaneous  surface;  and  by  its  cells 
having  the  type  of  squamous  epithelium.    As  these  cells  multiply 


40 


SUEGICAL   DISEASES. 


they  arrange  themselves  in  globular  masses.  The  outer  cells  ot 
these  masses  become  flattened  by  the  pressure  of  the  surrounding 
tissues,  while  those  near  the  centre  retain  their  expanded  form. 
These  are  the  laminated  capsules,  the  concentric  globes  or  nests 
of  cells,  which  are  characteristic  of  epithelioma  (Fig.  15).  In 
the  older  parts  of  the  disease  these  globes  will  be  found  com- 
pressed into  dense  masses  where  no  cellular  arrangement  is 
visible,  while  in  the  oldest  portions  they  present  only  the  ap- 
pearance of  granular  debris  in  the  interspaces  of  an  abundant 
fibrous  tissue. 

Fig.  15. 


Epithelioma ;  laminated  capsules,  x  200. 

Epithelioma  appears  to  originate  in  an  excessive  growth  of  the 
papillae  of  the  skin  or  mucous  membrane,  and  of  the  epithelium 
covering  them.  Sometimes,  however,  it  commences  among  the 
deeper  tissues.  As  a  general  rule  it  advances  slowly  at  first.  For 
years  it  may  remain  inactive,  making  little  or  no  progress.  Then 
it  may  begin  to  grow  more  rapidly,  springing  up  in  the  form  of 
warts,  tubercles,  cauliflower  excrescences,  &c.  Cracks  and  fissures 
appear  on  the  surface.  The  pain,  which  was  before  occasional 
and  trifling,  now  becomes  constant  and  acute.  The  patient's 
health  begins  to  sufier.  The  surface  of  the  tumour  ulcerates  and 
gives  rise  to  an  offensive  discharge,  while  the  disease  spreads 
apace,  invading  the  surrounding  tissues,  and  extending  to  the 
neighbouring  lymphatic  glands.  In  some  rare  instances  it  has 
given  rise  to  secondary  deposits  in  other  parts  of  the  body. 

Epithelial  cancer  is  most  frequently  seen  upon  the  muco- 
cutaneous surfaces,  the  lips,  the  anus,  the  penis,  the  labia,  &c. 
But  it  is  not  confined  to  these  situations.     It  may  begin  almost 


THE  CANCERS — CAKCINOMATA. 


41 


anywhere,  in  any  part  of  the  skin  or  mucous  membrane,  in  the 
lymphatic  glands,  or  even  in  the  bones. 

There  is  sometimes  an  hereditary  predisposition  to  epithe- 
lioma, and,  when  such  is  the  case,  long-continued  local  irritation 
seems  to  determine  its  seat — as,  for  example,  the  smoker's  cancer 
of  the  lip,  and  the  chimney-sweep's  cancer  of  the  scrotum.  Acrid 
discharges,  or  a  want  of  proper  cleanliness,  may  have  something  to 
do  with  its  frequent  occurrence  about  the  labia  or  anus.  It  has 
long  been  observed  that  those  who  have  congenital  phimosis 
are  more  liable  than  others  to  epithelial  cancer  of  the  penis ;  no 
doubt  in  consequence  of  the  irritation  caused  by  the  retained 
secretion. 

The  Eodent  ulcer  (lupus  exedens),  which  will  be  described 
hereafter,  is  probably  an  epithelioma.  Perhaps  it  may  be  viewed 
as  an  epithelioma  which  never  goes  beyond  a  certain  early  stage 
of  development. 

The  variety  of  cancer  called  villous  may  be  regarded  as 
epithelioma  attacking  niucous  surfaces — for  example,  the  lining 
membrane  of  the  mouth  or  bladder. 

Colloid  or  gum  cancer  consists  of  an  alveolar  bed,  formed  of 
fibrous  tissues  arranged  in  large  circular  outlines,  and  filled  up 
with  semi-transparent  mucoid  substance.  It  has  but  few  vessels, 
and  grows  slowly.  The  cells  of  which  it  is  composed  are  large, 
spherical,  and  filled  with  the  same  gelatinous  material  in  which 
they  are  imbedded.  It  would  seem  that  they  are  too  large  to 
travel  easily  through  the  lymphatics  ;  and  hence  this  form  of 
cancer  does  not  readily  disseminate  itself.  It  is  a  disease  of  adult 
life.     It  is  most  frequently  seen  in  the  intestines ;  though  it  may 

Fig.  16. 


Melanosis  infiltrating  muscle,  x  300. 

occur  elsewhere,  and  is  sometimes  found  blended  with  masses  ot 
medullary  cancer.  It  may  be  regarded  as  forming  the  link  be- 
tween the  cancers  and  cystic  disease  of  the  ovary. 


42 


SUEGICAL  DISEASES. 


Melanosis. — Some  examples  of  cancer — more  particularly  those 
which  spring  from  the  choroid  or  skin — are  distinguished  by  the 
presence  of  pigmentary  matter,  and  some  writers  have  described 
these  as  a  distinct  variety  under  the  name  of  llacJc  cancer.  But 
their  growth  and  development  is  essentially  the  same  as  that  of 
the  other  cancers,  only  their  cells  retain  the  power  of  selecting 
pigments  from  the  blood — a  power  derived  from  the  tissue  in 
which  they  originated.  The  pigment  is  scattered  throughout  the 
mass  in  the  form  of  minute  granules,  which  gradually  coalesce 
and  become  small  masses  (Fig.  16).  In  other  respects  the 
growth  closely  resembles  encephaloid.  Of  this  we  have  a  remark- 
able proof  in  the  fact  that  a  pigmented  cancer,  springing  from 
the  choroid,  may  be  black  within  the  globe  of  the  eye,  and  white 
(ordinary  encephaloid)  when  it  has  burst  through  the  coats,  and 
affected  non-pigmented  tissues.  The  disease  may  be  confined  to 
a  single  spot,  or  it  may  gradually  disseminate  itself  until  it  has 
invaded  a  wide  area  and  implicated  many  organs.     Tig.  17  is 

taken  from  a  case  which  I  had  the 
opportunity  of  watching  from  be- 
ginning to  end.  The  patient 
was  a  woman  aged  47.  The 
disease  commenced  in  a  mole  on  the 
third  toe  of  the  left  foot.  Two 
years  and  a  half  from  the  time 
when  she  first  began  to  feel  irrita- 
tion and  pain,  the  thigh  was  in 
the  condition  represented.  It  was 
stained  almost  all  over  a  uniform 
grey  colour,  and  speckled  with  an 
infinite  number  of  black  nodules, 
like  small  shot.  Four  months  later 
the  patient  died,  and  it  was  found 
that  all  the  muscles  of  the  left  thigh, 
as  well  as  the  lymphatic  system 
generally,  and  the  liver  and  lungs, 
were  infiltrated  with  the  disease. 
Fig.  16  was  made  from  the  left 
sartorius  muscle. 

The  diagnosis  of  cancer  is  not 
always  easy,  especially  in  its  earlier 
stages ;  and  yet  it  is  a  disease  which 
it  is  of  great  importance  to  detect 
before  it  has  made  much  progress. 
Scirrhus  may  generally  be  distinguished  by  paying  attention  to 
its  situation,  its  hard,  nodular  outline,  the  age  and  sex  of  the 


Diffuse  melanosis  of  the  thigh. 


THE  CANCERS — CARCINOMATA. 


43 


patient,  the  family  history,  the  stabbing  character  of  the  pain, 
the  retraction  of  the  surrounding  tissues,  the  implication  of 
lymphatic  glands,  and  the  impaired  state  of  the  health. 

In  the  case  of  encephaloid  disease,  the  diagnosis  is  more  difficult. 
It  is  more  likely  to  be  confounded  with  other  tumours,  and  we 
have  fewer  points  to  guide  us.  Still,  the  rapidity  of  growth,  the 
smooth,  uniform  aspect  of  the  tumour,  with  dilated  veins  coursing 
over  it,  and,  if  need  be,  a  microscopical  examination  ^. 
of  its  contents,  will  go  far  to  establish  its  nature. 

The  causes  of  cancer  are  very  obscure.  As  we 
have  said,  it  is,  to  a  certain  extent,  an  hereditary 
disease.  The  tendency  to  it  appears  to  increase 
steadily  as  age  advances.  In  some  instances  it 
would  seem  that  the  predisposition  is  called  into 
activity  by  a  blow  or  a  wound  or  a  long-standing 
irritation.  But  much  more  often  it  cannot  be 
traced  to  any  cause.  In  the  majority  of  cases  it 
has  a  constitutional  origin,  and  that  of  so  subtle 
a  nature  that  we  are  as  yet  unable  to  grasp  it. 

Treatment  of  Cancer. — Constitutional  treat- 
ment, however  useful  it  may  be  in  improving  the 
patient's  health,  and  mitigating  his  sufferings,  has 
no  power  to  disperse  the  tumour,  or  to  arrest  its 
growth. 

Our  only  hope  of  effecting  a  cure  lies  in  early 
and  complete  removal.  Yet  it  is  seldom  indeed 
that  a  cancer  can  be  said  to  be  cured  by  extirpa- 
tion. In  most  cases  all  that  can  be  done  by  this 
means  is  to  promote  the  patient's  comfort,  and 
to  prolong  his  life.  If  the  disease  is  very  exten- 
sive, ramifying  among  important  parts,  or  if  the 
patient's  health  is  much  impaired,  or  if  there  is 
reason  to  think  that  vital  organs  are  secondarily 
affected,  removal  is  almost  out  of  the  question. 

But  supposing  an  operation  to  be  admissible, 
what  means  shall  we  select  in  performing  it  ? 
Either  the  knife,  the  ecraseur,  or  the  galvanic- 
ecraseur,  the  ligature,  or  caustics  may  be  used. 
Undoubtedl}-^,  as  a  general  rule,  the  best  method  is 
excision.  If  the  tumour  is  of  moderate  size,  it 
may  be  easily  removed  by  the  knife,  under  chloro- 
form; and  the  clean-cut  surfaces  may  unite  by 
adhesive  inflammation,  or  be  left  to  granulate. 

If,  however,  the  patient  should  object  to  any  cutting  operation, 
we  may  propose  the  use  of  the  ecraseur  or  of  the  galvanic-ecraseur. 


44  SUEGICAL  DISEASES. 

or  of  the  ligature,  or  of  caustics  according  to  the  nature  and 
situation  of  the  disease.  Fig.  18  represents  Hicks'  ecraseur  for 
the  removal  of  uterine  polypi.  It  carries  a  wire  cord  composed 
of  several  strands,  and  is  a  useful  instrument  in  dealing  with 
some  of  the  smaller  cancers. 

Many  ways  have  been  proposed  for  destroying  cancers  by 
caustic,  and  various  agents  have  been  tried.  Among  these  we 
may  mention  the  strong  sulphuric  and  nitric  acids,  the  paste  com- 
posed of  potash  and  lime  (Vienna  paste),  and  the  sulphate  or 
chloride  of  zinc  applied  either  in  the  form  of  powder  or  paste 
(Pell's  paste),  or  in  the  shape  of  "  caustic  arrows."  These  con- 
sist of  the  caustic  made  into  a  paste  with  flour,  baked  to  hardness, 
and  then  cut  into  small-pointed  strips.  They  may  be  inserted 
into  or  around  the  tumour,  through  punctures  in  the  skin.  The 
pain  which  is  given  by  caustics  varies  much.  Sometimes  it  is 
not  great ;  at  other  times  it  is  severe  and  protracted.  Perhaps, 
on  an  average,  it  may  be  expected  to  last  for  four  or  five  hours. 

Narcotics  are  invaluable  in  alleviating  pain  and  procuring 
sleep.    Opium,  conium,  or  henbane  may  be  given  freely  (F.  10, 53). 

Tonics  may  do  much  to  improve  the  patient's  general  health 
and  to  enable  him  to  resist  the  disease.  The  preparations  of  iron, 
quinine,  or  cod-liver  oil  should  be  prescribed ;  while  at  the  same 
time  care  should  be  taken  that  the  patient  has  a  generous  diet, 
combined  with  moderate  exercise  in  the  open  air ;  and  he  should 
be  advised  to  avoid  all  such  use  of  the  part  as  tends  to  keep  up 
local  irritation. 

SCROFULA,  STRVIVIA,  AND  TUBERCUIiOSIS. 

Scrofula  (or  struma)  is  the  name  given  to  a  constitutional 
affection  of  whose  essential  nature  we  are  ignorant,  but  which 
evidently  depends  upon  a  deficient  or  depraved  nutrition,  and 
which  declares  itself  by  certain  outward  marks.  It  is  most  prone 
to  appear  in  early  life.  Its  symptoms  are  slow  and  insidious  in 
their  progress,  but  afford  unmistakable  evidence  of  debility. 

Though  it  may  occur  in  almost  any  one,  it  is  chiefly  met  with 
in  individuals  of  two  very  different  aspects : — (1).  The  sanguine — 
with  clear  complexions,  delicate  features,  graceful  outlines,  fine 
skins,  large  lustrous  eyes  with  long  silky  lashes,  and  quick, 
lively  intellects — children  who  are  beautiful  in  person,  precocious 
in  mind,  and  almost  unnaturally  good  and  docile.  Wordsworth 
seems  to  be  describing  such  a  child  when  he  says — 

"  I  see  the  dark -brown  curls,  the  brow, 
The  smooth  transparent  skin, 
Refined  as  with  intent  to  show 
The  holiness  within." 

Jewish  Family  at  St.  Goar. 


SCROFULA,   STRUMA,    AND  TUBERCULOSIS.        45 


(2).  The  flilegmatic — with  muddy  complexions,  coarse  features, 
thick  lips,  dull  heavy  eyes,  large  joints,  and  awkward,  stunted, 
or  deformed  figures.  In  persons  of  this  temperament  the 
intellectual  faculties  are  sometimes  obtuse,  sometimes  capable  of 
great  and  sustained  exertion.  It  has  been  customary  to  point  to 
Dr.  Samuel  Johnson,  the  lexicographer,  as  a  type  of  this  class. 
Boswell  tells  us  that  even  in  early  life  "  his  immense  structure  of 
bones  was  hideously  striking  to  the  eye,  and  the  scars  of  the 
scrofula  were  deeply  visible." 

These  external  characters  are  accompanied  by  a  weak,  irritable, 
and  imperfect  digestion,  a  feeble  circulation,  a  relaxed  state  of  the 
muscles,  and  a  tendency  to  derangements  of  health. 

The  scrofulous  constitution  is  often  inherited ;  but  it  may  also 
be  produced  by  unfavourable  conditions  of  life,  as  a  want  of  pro- 
per nourishment,  fresh  air,  sunlight,  clothing,  exercise,  &c. 

The  parts  where  it  most  frequently  shows  itself  are  the  bones, 
the  joints,  the  lymphatic  glands,  the  skin,  and  the  eyes.  In 
internal  organs  it  gives  rise  to  diseases  which  fall  under  the  care 
of  the  physician,  such  as  phthisis  pulmonalis,  tabes  mesenterica,  or 
tubercular  meningitis.  -p.     ^q 

In    the    skin,   the  cornea,  '      *    ' 

and  the  mucous  membranes  it 
occasions  a  low  and  unhealthy 
inflammation,  with  ulcera- 
tion ;  while  in  the  lymphatic 
glands  and  bones  it  leads  to 
chronic  inflammation,  the 
deposit  of  tubercle,  and  sup- 
puration. 

The  accompanying  illus- 
tration (Fig.  19)  represents 
chronic  enlargement  of  the 
cervical  glands  in  a  strumous 
boy,  aged  14,  who  was  under 
my  care  at  Charing  Cross 
Hospital.  As  it  is  the  can- 
cellated structure  of  bones 
which  is  most  liable  to  suffer, 
the  neighbouring  joints  are 
in  great  danger  of  being 
secondarily  affected.  Some- 
times the  scrofulous  disease 
appears  to  begin  in  the  joint 
itself,  and  to  spread  to  the  adjacent  bones  (see  p.  178). 

Such  being  the  habit  of  body  in  scrofulous  persons  a  very 


Chronic  enlargement  of  the 
cervical  glands. 


46  SURGICAL  DISEASES. 

slight  cause  is  sufficient  to  determine  some  manifestation  of  the 
disease.  Thus,  a  sprain  may  be  followed  by  disease  of  the  joint, 
a  long  walk  by  enlargement  of  the  inguinal  glands,  or  the  irrita- 
tion of  dentition — more  particularly  the  eruption  of  wisdom  teeth 
— by  the  enlargement  of  those  in  the  neck. 

Tubercle  is  the  morbid  material  which  is  deposited  in  lym- 
phatic glands,  bones,  internal  organs,  or  elsewhere,  as  a  result 
of  strumous  disease.  Its  essential  nature  and  the  mode  of  its 
production  are  involved  in  much  obscurity.  It  would  appear, 
however,  to  be  a  degraded  form  of  plastic  material,  the  result  of 
an  affection  of  the  lymphatic  system,  produced  by  faulty  and 
perverted  nutrition. 

Tubercle  is  met  with  under  two  forms — either  as  minute  beads 
of  a  gre}%  semi-transparent  appearance  and  a  firm  consistence ; 
or  as  a  soft,  yellow,  opaque  substance  like  cheese.  The  "  grey 
granulations"  seem  to  be  nothing  more  than  the  early  stage  of 
the  "  crude  tubercles.'^ 

Under  the  microscope  tubercle  presents  a  homogeneous  mass,  in 
which  are  seen  some  imperfect  cells. 

Chemically  it  consists  of  albumen,  phosphate  and  carbonate  of 
lime,  together  with  a  little  oil. 

Tubercle  is  never  organized,  and  never  entirely  absorbed.  In 
a  few  fortunate  cases  it  withers  into  a  dry  and  chalky  substance ; 
but  in  the  great  majority  of  instances  it  softens,  suppurates,  and 
gives  rise  to  abscess. 

The  treatment  of  scrofula  is  partly  constitutional  and  partly 
local.  It  has  been  said  that  the  disease  is  one  of  debility  and 
faulty  assimilation.  Everything,  therefore,  must  be  done  which 
can  promote  digestion  and  nutrition,  and  improve  the  general 
health.  By  careful  attention  to  this  rule  the  active  manifestation 
of  the  disease  may  be  prevented,  even  in  those  who  have  an  here- 
ditary tendency  to  it.  The  patient  should  live  in  a  pure  atmo- 
sphere— if  possible,  in  an  elevated  situation,  or  at  the  seaside.  He 
should  have  plenty  of  sun-light, 

"  Since  light  so  necessary  is  to  life, 
Nay,  almost  life  itself." 

Milton's  Samson  Agonistes. 

His  diet  should  be  plain  but  nutritious,  including  a  large  propor- 
tion of  animal  food,  and  given  with  regularity.  His  clothes 
should  be  sufficiently  warm,  and  he  should  be  encouraged  to  take 
a  moderate  amount  of  exercise  in  the  open  air.  The  surgeon 
must  pay  attention  to  the  state  of  the  skin  and  of  the  secretions. 
A  mild  aperient  or  alterative  should  be  given  occasionally  ]  and, 
if  other  circumstances  permit,  a  cold,  tepid,  or  sea-water  bath 


SCROFULA,    STRUMA,  AND  TUBERCULOSIS.        47 

should  be  used  every  morning.  At  the  same  time  the  prepara- 
tions of  iron,  or  of  iodine,  or  cod-liver  oil  may  be  prescribed  with 
great  advantage;  and  the  extract  of  malt  or  koumiss  may  be 
useful.  Some  natural  mineral  waters — more  particularly  those  of 
Woodhall  in  Lincolnshire,  and  Kreutznach  in  Rhenish  Prussia — 
are  often  of  great  service  in  the  treatment  of  scrofulous  cases  : 
while  in  many  instances  a  sea  voyage  is  the  best  thing  that  the 
surgeon  can  recommend. 

The  local  treatment  must  vary  according  to  the  particular  form 
and  stage  of  the  disease.  The  inflammation,  both  before  and 
after  suppuration  has  taken  place,  must  be  treated  on  the  same 
principles  which  guide  us  in  dealing  with  inflammation  generally. 
But  after  all  that  can  be  done  there  are  a  few  obstinate  and  in- 
veterate cases  which  will  remain,  as  they  were  in  Shakspeare's 
time,  "  the  mere  despair  of  surgery"  (Macbeth,  iv.  3) — cases  in 
which  some  of  the  larger  joints  are  diseased,  or  in  which  the  whole 
extent  of  a  limb  is  riddled  with  sinuses,  and  for  the  cure  of  which 
nothing  short  of  a  severe  operation — an  excision  or  an  amputa- 
tion— will  suffice.  When,  however,  the  patient's  constitution  is 
impaired,  and  his  strength  undermined  by  long-continued  suflfer- 
ing,  he  is  not,  of  course,  in  a  very  favourable  condition  for  under- 
going any  operative  treatment. 


PART   11. 

INJURIES. 


THE  ARREST    OF    HEMORRHAGE. 

HjEMOERHAGE  is  of  three  kinds — arterial,  venous,  and  capillary. 

In  arterial  hsemorrbage  the  blood  leaps  forth  in  bright,  red 
jets.  In  venous  hsemorrbage  it  wells  out  in  a  dark  purple 
stream.  In  capillary  haemorrhage  it  oozes  from  the  general 
surface.     We  shall  speak  of  each  of  these  three  varieties  in  turn. 

Arterial  Haemorrhage. — It  will  be  well  to  study,  first,  the 
natural,  and  second,  the  artificial  arrest  of  haemorrhage. 

Natural  arrest. — This  must  be  considered  under  two  heads — 
(1)  the  temporary,  and  (2)  the  permanent  arrest  of  bleeding. 

1.  When  an  artery  is  cut  across  its  coats  both  contract  and 
retract.  They  contract  so  as  to  reduce  the  size  of  its  orifice,  and 
diminish  the  jet  of  blood.  They  retract  so  as  to  leave  the  sheath 
projecting  beyond  them.  On  the  rough  areolar  surface  of  this 
sheath,  as  well  as  in  the  extremity  of  the  vessel  itself,  the  blood 
is  arrested,  and  forms  a  coagulum.  This  coagulum  occludes  the 
mouth  of  the  artery.  In  some  cases  there  are  other  circumstances 
which  come  to  our  aid.  As  haemorrhage  proceeds,  the  force  of 
the  heart  decreases,  while  at  the  same  time  the  blood  itself 
becomes  more  and  more  disposed  to  coagulate.  These  are  the 
means  by  which  bleeding  is  temporarily  arrested. 

2.  From  the  cut  edges  of  the  artery  plastic  material  is  poured 
out,  which  blends  with  the  fibrinous  clot,  and  gradually  the 
wl)ole  becomes  vitalized.  By  degrees  the  colouring  matter  of 
the  coagulum  is  absorbed,  aud  the  fibrine  alone  is  left. 

Within  the  artery  itself  the  blood  stagnates,  and  the  fibrine  is 
deposited — forming  the  "  internal  coagulum."  This  is  of  a  conical 
shape  with  the  apex  directed  upwards.  At  the  same  time  fibrine 
is  also  deposited  on  the  lining  membrane  of  the  artery  adjacent  to 
the  cut  end.  This  is  sometimes  called  the  "  secondary  internal 
clot."  The  arterial  coats  continue  to  contract  upon  the  "  internal 
coagulum,"  and  become  adherent  to  it,  the  "  secondary  internal 


THE  AEEEST  OF  HEMORRHAGE.  49 

clot"  blending  with  the  "  internal  coagnlum."  The  fibrlne  of  this 
coagulum  becomes  firadually  organized  into  fibro-cellular  tissue,  and 
after  the  lapse  of  time  nothing  is  left  but  a  fibrous  cord.  These 
are  the  means  by  which  the  artery  becomes  permanently  occluded. 

When  an  artery  is  torn  across  the  arrest  of  hsemorrhage  takes 
place  somewhat  differently.  The  two  inner  coats  yield  to  the 
lacerating  force  before  the  outer  one  gives  way.  The  outer  one 
is  thus  drawn  to  a  point  beyond  the  two  inner  ones.  In  thia 
way  a  double  barrier  is  formed  to  the  passage  of  the  blood  ;  first 
by  the  outer  coat,  and  secondly  by  the  slieath,  as  in  the  former 
case.  A  conical  clot  with  its  apex  downwards  forms  in  the  space 
between  the  two  inner  and  the  outer  coats;  while,  as  before,  an 
"  internal  coagulum" — a  conical  clot  with  the  apex  upwards — 
forms  in  the  channel  of  the  artery  itself.  The  subsequent  changes 
are  the  same  as  in  the  former  case. 

When  an  artery  is  wounded,  or  partially  divided,  it  is  important 
to  observe  how  Nature  provides  for  the  arrest  of  ha3morrhage. 
The  blood  which  is  poured  out  at  the  aperture  lodges  in  the 
sheath  and  adjacent  tissues,  coagulates,  and  presses  upon  the 
artery.  By  this  means  the  calibre  of  the  vessel  is  reduced,  and 
its  position  relatively  to  the  wound  in  the  skin  is  somewhat 
altered.     Thus  the  hsemorrhage  is  temporarily  arrested. 

Permanent  closure  takes  place  by  adhesive  inflammation  in  the 
wound  itself.  But  in  many  cases  the  effusion  of  plastic  material 
is  so  great  as  to  lead  to  the  entire  occlusion  of  the  artery.  A 
longitudinal  incision  will  always  heal  more  favourably  than  a 
transverse  one.  When  the  wounded  artery  is  of  large  size  union 
by  adhesion  can  hardly  be  expected.  A  traumatic  aneurism  will 
usually  be  the  result  of  such  an  injury. 

Artificial  arrest. — The  surgeon  has  various  means  at  his  dis- 
posal for  stopping  the  flow  of  blood.  He  need,  therefore,  never 
fear  haemorrhage,  provided  the  bleeding  point  is  within  his  reach, 
for  then  it  can  always  be  controlled,  at  any  rate  for  a  time. 

The  position  of  the  part  should  be  studied  ;  the  seat  of  injury 
being  raised  as  high  as  possible  above  the  level  of  the  heart. 

Cold  is  very  useful  in  constricting  the  vessel.  It  may  be 
enough  merely  to  expose  the  wound  to  the  air ;  or  cold  water  or 
ice  may  be  applied  according  to  circumstances. 

Pressure  may  be  employed  by  means  of  the  fingers,  a  tourni- 
quet, or  a  graduated  compress,  according  to  the  nature  of  the 
case  and  the  situation  of  the  vessel.  A  graduated  compress 
(Fig.  20)  is  formed  of  several  folds  of  lint  laid  one  on  the  top  of 
the  other,  each  fold  being  a  little  smaller  than  the  one  below  it. 
In  this  way  a  pyramidal  pad  is  made,  and  when  it  is  applied  the 
apex  is  directed  downwards  and  placed  just  over  the  point  upoa 

s 


50 


INJURIES. 


! 


iVS->-— .-: 


which  the  surgeon  desires  to  exert  the  greatest  amount  of  pres- 
sure.     The  pad,   or  compress,  may  be  of  any  shape  that  suits 
the  part ;  or  of  any  thickness,  according  to 
Fig.  20.  i\^Q  amount  of  force   which  we  wish  to  use ; 

for  the  greater  the  thickness  the  greater  will 
v>>:'->>^     '    be  the  degree  of  pressure  that  it  is  capable 
of  exerting. 

If  such  a  compress  is  secured  by  a  nodose 
bandage  it  is  capable  of  exerting  a  great 
degree  of  force. 

The  nodose  bandage  (nodus,  a  knot)  is 
perhaps  most  frequently  applied  to  the  temporal  artery,  and  we 
shall  describe  it  as  it  is  used  in  this  situation ;  but  it  may  be 
modified  to  suit  various  localities,  and  it  may  often  be  employed 
as  a  sort  of  extemporized  tourniquet  to  make  deep  pressure  upon 
a  particular  spot. 

It  requires  a  double-headed  arm-bandage,  and  a  graduated  com- 
press.    The  compress  is  first  laid 
Fig.  21.  upon  the  temple,  on  the  spot  upon 

which  it  is  desirable  to  exert  the 
pressure.  The  central  portion  of 
the  bandage  is  then  applied  over 
the  compress,  and  the  two  rollers 
are  carried  horizontally  round  the 
head;  one  to  the  right  hand  and 
the  other  to  the  left,  to  the  oppo- 
site temple,  where  they  cross  one 
another,  and  are  brought  round 
again  to  the  compress.  They  are 
now  twisted  upon  one  anotlier, 
forming  a  knot  over  the  compress, 
and  being  turned  so  that  one  may 
be  conducted  over  the  head  and 
the  other  under  the  chin  to  the 
opposite  temple.  Here  they  meet 
and  cross  one  another,  and  are 
Nodose  bandage.  brought     round    again    to     the 

compress  (Fig.  20),  Having 
arrived  at  the  compress,  they  are  again  twisted  upon  one  another, 
so  as  to  make  another  knot.  The  operator  is  now  enabled  to 
carry  the  roller  horizontally  round  the  head  as  at  the  first  turn. 
When  as  many  twists  as  are  necessary  have  been  made  over  the 
compress,  the  bandage  may  be  finished  off"  with  two  or  three 
circular  turns  round  the  head. 

The  twists  or  knots,  from  which  the  bandage  takes  its  name, 


THE  ARREST  OF  ILEMORRHAGE.  r,l 

sliould  all  fall  upouthegraduatedcompres?,  and  if  they  are  rightly 
applied  they  are  capable  of  exerting  a  great  degree  of  pressure. 
The  bandage  may  be  secured  on  the  opposite  temple  by  passing 
oue  or  two  pins  through  the  point  where  the  horizontal  and 
vertical  folds  cross  one  another. 

Styptics. — Various  substances  are  employed  as  styptics.  Some 
of  these  act  by  coagulating  the  blood,  others  by  constricting  the 
coats  of  the  vessels.  To  promote  the  coagulation  of  the  blood,  to 
give  it  a  tine  mesh-work  whereupon  the  fibrine  may  be  deposited, 
it  is  a  popular  practice  to  apply  some  cobwebs,  or  a  little  fretted 
blotting-paper  to  the  bleeding  surface.  The  use  of  the  former  is 
alluded  to  in  Shakspeare's  "  Midsummer  Night's  Dream,"  where 
Bottom  says  to  the  fairy  named  Cobweb,  "  I  shall  desire  you  of  more 
acquaintance,  good  master  Cobweb.  If  I  cut  my  finger  I  shall 
make  bold  with  you."  Such  applications  as  these  imitate  the  natural 
haemostatic  process  wherein  the  blood  coagulates  upon  the  rough 
areolar  sheath  of  the  divided  artery.  Of  the  styptics  which  act  by 
their  astringent  power  upon  the  coats  of  the  vessels  the  most  useful 
are  the  perchloride  of  iron,  gallic  acid,  alum,  zinc,  and  matico. 

The  actual  cautery  is  a  certain,  though  a  severe,  means  of  stop- 
ping bleeding.  It  acts  by  coagulating  and  hardening  the  tissues. 
It  is  particularly  suitable  to  some  situations  whei'e  it  is  diflBcult  to 
apply  ligatures — the  interior  of  the  mouth,  for  example.  The 
lunar  caustic  has  the  same  effect,  only  its  action  is  more  superficial. 

Torsion. — The  bleeding  artery  may  be  seized  wdth  a  forceps, 
drawn  gently  forwards,  and  twisted  two  or  three  times.  The 
part  that  is  included  in  the  forceps  should  not  be  twisted  com- 
pletely ofi'.  It  does  not  slough,  so  that  there  need  be  no  fear  that 
it  wall  act  as  a  putreftictive  foreign  body.  When  torsion  is  em- 
ployed in  this  way,  the  eflect  is  to  rupture  the  two  internal  coats  of 
the  artery,  which  become  more  or  less  incurved  by  their  own 
elasticity,  while  the  external  coat  is  folded  over  the  end  of  the 
vessel. 

Fig.  22  illustrates  this  point.  It  is  taken  from  a  microsco- 
pical section  which  I  obtained  when  making  experiments  on  the 
carotid  of  a  rabbit.  The  artery  had  been  closed  by  torsion.  The 
ruptured,  retracted,  and  incurved  inner  coats  are  well  seen,  as 
well  as  the  internal  coagulum  and  the  secondary  clots. 

Torsion  has  long  been  practised  upon  small  arteries,  and  for 
such  all  surgeons  are  agreed  that  it  is  a  good  method.  But  in 
the  case  of  large  arteries — e.g.,  the  femoral  or  the  brachial — it 
seems  neither  so  convenient  nor  so  safe  as  the  ligature. 

Acupressure  was  recommended  to  the  profession  by  Sir  James 
Simpson  as  a  means  of  arresting  haemorrhage.  It  consists  in 
passing  a   needle   across    the   artery,  through   the  tissues,  and 

E  2 


5-2 


INJUEIES. 


making  pressure  upon  it  by  the  elasticity  of  the  tissues  themselves. 
As  a  general  practice  acupressure  lias  not  met  with  much  favour. 
It  is  open  to  the  great  objection  that  it  only  presses  together  the 

Fig.  22. 


Artery  closed  by  torsion,  x  €0. 

sides  of  the  divided  artery  and  does  not  rupture  the  two  inner 
coats,  upon  which  so  much  of  the  safety  of  the  patient  depends. 
There  are,  however,  some  situations  in  which  it  is  extremely  use- 
ful— e.g.,  there  is  no  readier  way  of  stopping  the  bleeding  from  a 
superficial  artery,  such  as  the  radial  or  ulnar,  than  by  passing  a 
needle  across  it  so  as  to  compress  it. 

The  safest  and  most  convenient  way  of  stopping  the  flow  of 
blood  from  an  artery  is  to  put  a  ligature  upon  it.  When  an 
artery  presents  itself  upon  a  cut  surface  it  is  to  be  seized  with  a 
forceps,  drawn  gently  forward,  and  a  ligature  passed  round  it. 
The  ligature  should  then  be  tied  with  a  reef  knot,  and  one  of  the 
ends  cut  off.  It  is  usual  to  employ  hempen  ligatures,  but  from 
time  to  time  various  substances — chiefly  animal  membranes — 
have  been  tried  in  the  hope  of  finding  something  which  would  not 
act  as  a  foreign  body,  but  would  gradually  undergo  liquefaction 
and  absorption.  With  tbis  object  Mr.  Lister  has  recommended 
carbolized  catgut.  Fig.  23  represents  a  thin  section  of  the  carotid 
artery  of  a  rabbit  twelve  hours  after  it  had  been  ligatured  with 
carbolized  catgut.  The  clear  homogeneous  circles  are  the  ligature 
cut  transversely.     On  the  left  of  the  drawing  the  earliest  stages 


THE   ARREST  OF  HAEMORRHAGE.  53 

in  the  formation  of  the  internal  coagulum  and  the  secondary  clots 
are  well  seen.  When  any  material  like  catgut  is  used  both  ends 
are  cut  off  short,  and  the  surgeon  aims  at  healing  the  wound  as 

Fig.  23. 


Artery  closed  by  catgut  ligature,  x  60. 

rapidly  as  possible,  leaving  the  noose  and  knot  to  be  absorbed. 
When  the  ligature  is  drawn  tight  the  internal  and  middle  coats 
of  the  artery  give  way  and  turn  inwards,  while  the  external  one 
is  drawn  over  the  orifice.  An  internal  coagulum  immediately 
begins  to  form  in  the  channel  of  the  vessel,  and  plastic  lymph  is 
poured  out  from  the  divided  coats  of  the  artery,  both  on  the  distal 
and  proximal  sides  of  the  ligature,  which  helps  to  agglutinate 
and  close  the  opening. 

When  a  vessel  has  been  completely  severed  by  a  wound  both 
tlie  cut  ends  should  be  secured. 

Mr.  Spencer  Wells  has  recently  drawn  attention  to  the  value 
of  forcipressure  as  a  haemostatic — i.e.,  the  simple  compression  of 
the  bleeding  artery  by  forceps.  This  may  either  be  done  by  the 
little  "  bulldog"  forceps,  which  have  long  been  in  use,  or  by  the 
larger  forceps — something  like  polypus  forceps — which  Mr. 
Wells  has  devised.  This  instrument  is  furnished  with  serrated 
teeth,  and  the  handles  are  secured  by  a  catch.  By  this  means 
the  bleeding  vessel  is  forcibly  compressed,  and  its  coats  squeezed, 
or  almost  crushed,  together.  This  alone  is  often  sufficient  to 
stop  the  bleeding,   especially  if  the  compressing  force  is  con- 


5i  INJURIES. 

tinned  for  a  few  minutes.  But,  if  need  be,  torsion  may  be  prac- 
tised in  addition,  or  a  ligature  may  be  passed  over  the  end  of  the 
forceps. — (£rit.  Med.  Jour.,  June  21,  1879.) 

When  called  to  a  case  of  haemorrhage  the  first  thing  the  surgeon 
should  do  is  to  remove  all  bandages,  dressings,  &c.,  and  to  see 
exactly  from  whence  the  bleeding  proceeds.  Sometimes  the  mere 
exposure  of  a  wound  to  the  air  may  do  much  to  arrest  the 
haemorrhage.  If  blood  is  flowing  fast  the  surgeon  should  apply 
a  tourniquet,  or  direct  an  assistant  to  compress  the  main  artery 
above  the  seat  of  injury,  while  he  removes  the  clots,  and  sponges 
out  the  wound.  If  there  is  a  jet  of  arterial  blood  he  should  take 
up  the  bleeding  point  with  a  forceps,  and  have  a  ligature  thrown 
around  it.  If  the  hsemorrhage  consists  in  a  general  oozing  from 
the  cut  surface,  the  part  should  be  freely  exposed  to  the  air,  and 
well  washed  with  a  stream  of  cold  water,  and  then  pressure 
should  be  applied  by  means  of  a  pad  and  bandage.  If  the  blood 
is  welling  up  from  the  bottom  of  a  punctured  wound,  local 
pressure  by  means  of  a  graduated  compass  should  be  tried,  and 
at  the  same  time  a  tourniquet  should  be  applied  to  the  main 
artery  above  the  seat  of  injury.  If  these  means  fail,  the  wound 
must  be  enlarged  and  both  ends  of  the  bleeding  vessel  secured. 
If  this  is  found  impracticable,  the  artery  must  be  tied  in  the 
upper  part  of  its  course. 

Whenever  it  is  possible  the  surgeon  should  tie  the  bleeding 
vessel  at  the  seat  of  injury.  He  is  not  justified  in  making  afresh 
wound  and  cutting  down  upon  the  artery  in  the  upper  part  of 
its  course,  unless  it  is  absolutely  necessary  to  do  so  in  order  to 
save  the  patient's  life. 

In  cases  of  emergency  a  tourniquet  may  be  extemporized  by 
taking  a  cork,  a  stone,  or  any  other  suitable  substance,  folding  it 
in  lint,  and  laying  it  upon  the  main  artery. 
Fig.  24.  Upon  this  pressure  may  be  made  by  passing 

a  handkerchief  or  a  bandage  round  the 
limb,  and  tying  it  in  a  knot.  Then,  if  a 
piece  of  stick  be  introduced  into  the  knot 
and  twisted  round,  a  great  degree  of  force 
may  be  exerted  upon  the  pad  (Pig.  24). 

If  hsemorrhage  follows  an  operation,  and 
continues  in  spite  of  all  that  can  be  done 
by  position,  pressure,  cold,  &c.,  the  surgeon 
should  not  hesitate  to  re-open  the  wound, 
and  search  for  the  bleeding  point.  It  is 
better  that  the  patient  should  suffer  a  little 
pain  than  that  he  shoild  go  on  losing  blood. 

Secondary  Abteeial  H^moeehage,  that  is  to  say,  hsemor- 


THE  AREEST   OF   HEMORRHAGE.  55 

rhage  whicli  comes  on  after  the  bleeding  has  once  been  controlled, 
may  occur  at  various  periods,  since  it  depends  upon  different 
causes. 

1.  It  may  come  on  in  a  few  hours  after  an  accident  or  opera- 
tion. Vessels  from  which  no  blood  issued  at  the  time  the  wound 
was  first  dressed,  on  account  of  the  collapse  of  the  patient,  may 
begin  to  bleed  as  soon  as  he  gets  warm  in  bed,  and  recovers 
from  the  shock  he  has  sustained.  This,  as  Mr.  Spence  suggests, 
should  be  called  "  reactionary  haemorrhage." 

2.  Unhealthy  inflammation  may  take  place  in  the  wound 
within  a  few  days,  sloughs  may  occur,  and  vessels  may  be  opened  up 
in  this  way.  Or  the  artery  alone  may  ulcerate  or  slough.  When 
these  accidents  happen,  styptics  or  pressure  may  be  tried ;  but  more 
often  a  ligature  at,  or  above,  the  seat  of  disease  will  be  required. 

3.  When  the  ligature  separates  in  the  course  of  ten  or  fifteen 
days,  bleeding  may  ensue ;  the  line  of  ulceration,  by  which  the 
ligature  normally  separates,  having  spread,  and  opened  up  the 
artery.  In  such  a  case,  it  will  be  needful  to  enlarge  the  wound, 
and  tie  the  vessel  again.  Sometimes  it  may  be  necessary  to 
make  a  fresh  incision  and  secure  the  artery  in  a  higher  part  of 
its  course;  and  even  after  this  has  been  done,  haemorrhage  may 
again  occur  in  the  wound,  as  soon  as  the  collateral  circulation  has 
become  established.  This  is  a  form  of  secondary  haemorrhage 
which  is  less  likely  to  occur  now  that  it  is  so  usual  to  employ 
a  ligature  of  animal  membrane,  and  to  cut  the  ends  ofi^  short. 

Venous  HjEMOEehage. — The  surgeon  should  first  of  all  make 
sure  that  there  is  no  constriction  of  the  vein  above  the  seat  of 
injury ;  and  then  he  may  apply  pressure.  Much  less  force  is 
required  to  control  a  vein  than  an  artery.  Sometimes,  when  a 
large  vein  presents  itself  upon  an  exposed  surface,  it  may  be 
closed  by  a  ligature ;  but,  as  a  rule,  it  is  neither  necessary  nor 
advisable  to  tie  veins. 

Capillary  HjEMOEehage  may  generally  be  arrested  without 
difficulty  by  exposing  the  surface  to  the  air,  by  allowing  a  stream 
of  cold  water  to  fall  upon  it  from  a  little  height,  by  pressure, 
or  by  styptics. 

But  occasionally  we  meet  with  persons  who  present  what  is 
called  the  Ttcemorrhagie  diathesis,  and  in  such  even  a  capillary 
haemorrhage  may  be  followed  by  fatal  consequences.  They  are 
generally  young — more  often  males  than  females — of  a  delicate 
or  unhealthy  constitution,  which  shows  itself  by  swellings  about 
the  joints.  The  slightest  pressure  causes  a  bruise,  a  trifling  cut 
bleeds  alarmingly,  while  any  operation,  however  small,  is  attended 
by  the  greatest  danger  to  life. 

Treatment. — When  a  child  exhibits  this  tendency,  everything 


56  INJUEIES. 

should  be  done  to  secure  him  against  blows,  abrasions,  and  wounds 
of  all  kinds.  At  the  same  time  the  general  health  should  be 
improved  by  a  bracing  and  invigorating  plan  of  treatment.  The 
cold  batli,  sea  air,  moderate  exercise,  a  nutritious  diet,  combined 
with  cod-liver  oil,  the  preparations  of  iron,  or  the  mineral 
acids — these  are  the  best  remedies  that  we  can  recommend. 

If,  after  all  precautions,  bleeding  takes  place,  as  it  often  does, 
from  the  nose,  gums,  or  elsewhere,  full  and  frequent  doses  of  tur- 
pentine, gallic  acid  (F.  29),  or  other  styptics  should  be  given ; 
while  pressure — with  or  without  the  tincture  of  steel — or  ice  is 
tried  in  the  oidinary  way.  The  cautery,  whether  actual  or 
potential,  should  be  avoided,  as  being  likely,  when  the  slough 
separates,  to  increase  the  mischief. 

BRVXSES. 

A  bruise  or  contusion  is  an  injury  caused  by  a  fall,  a  wrench, 
or  a  blow  from  a  blunt  instrument,  without  rupture  of  the  skin. 
The  degree  of  such  injury  may  vary  widely— from  the  slightest 
discoloration  to  complete  disorganization.  The  severest  bruises 
are  those  which  are  produced  by  spent  cannon  balls.' 

When  a  bruise  is  inflicted,  the  subcutaneous  tissues  are  always 
more  or  less  lacerated.  Blood  is  poured  out.  There  is  ecehy- 
niosis.  The  discoloration  is  at  first  bluish-black ;  then  it  passes 
through  shades  of  violet,  green,  and  yellow,  until  by  the  end  of 
ten  days  or  a  fortnight  it  has  disappeared  altogether.  Even  in 
slight  cases  the  surface  is  tender,  and  there  are  pain  and  stiffness 
in  moving  the  part. 

The  injury  is  generally  confined  to  the  subcutaneous  areolar 
tissue  and  its  capillaries.  But  sometimes  an  artery  of  considerable 
size  is  torn  across,  and  blood  extravasated  in  large  quantity. 
Occasionally  the  whole  of  the  soft  tissues  are  involved  to  a  greater 
or  less  depth. 

Treatment. — When  the  injury  is  of  moderate  extent,  all  that 
we  have  to  do  is  to  guard  against  inflammatory  symptoms,  and 
to  promote  absorption.  With  this  view  the  part  should  be  kept 
at  rest,  and  assiduously  bathed  with  an  evaporating  or  discutient 
lotion  (F.  18, 19,  21).  A  poultice  mixed  with  black  bryony  root 
or  the  liydrochlorate  of  ammonia  is  highly  recommended  by  some 
{ F.  96).  It  is  astonishing  how  large  a  quantity  of  effused  blood  will 
sometimes  be  absorbed  (see  Fig.  95).  When  an  artery  has  been  torn 
across  and  is  bleeding,  we  must  endeavour  to  stop  the  haemorrhage 
by  position,  by  cold,  by  pressure  (possibly  acupressure),  or  by  the 
application  of  a  tourniquet.  If  the  bleeding  continues  in  spite  of 
all  that  can  be  done  by  these  means,  the  case  must  be  treated  as 
one  of  diffuse  aneurysm.    But  it  is  only  under  urgent  circumstance* 


WOUNDS.  57 

that  the  surgeon  is  justified  in  laying  open  a  fresh  ecchymosis,  and 
then  he  should  use  all  the  antiseptic  precautions.  If  inflammatory 
symptoms  arise  they  must  be  treated  in  the  ordinary  way  by 
poultices,  fomentations,  leeches,  and  an  antiphlogistic  regimen. 

For  the  treatment  of  those  cases  in  which  the  whole  of  the 
tissues  are  disorganized,  we  must  refer  our  readers  to  the  section 
on  Gunshot  Wounds. 

It  should  be  borne  in  mind  that  ecchymosis  may  be  produced 
by  other  causes  besides  those  we  have  enumerated — e.g.,  by  the 
application  of  a  cupping-glass,  by  scurvy,  by  purpura,  and  by 
low  fever. 

"WOUNDS 
are  divided  into  Incised,  Contused,  Lacerated,  Punctured,  and 
Poisoned. 

Incised  ivounds  are  inflicted  by  a  sharp  cutting  instrument. 
They  present  clean-cut  surfaces,  which  are  favourable  for  imme- 
diate union,  or  union  by  primary  adhesion.  The  chief  danger 
that  we  have  to  dread  from  an  uncomplicated  incised  wound  is 
bleeding.  The  various  methods  of  arresting  haemorrhage  have 
already  been  explained.  When  the  flow  of  blood  has  ceased,  the 
surgeon  should  see  that  the  wound  is  free  from  all  extraneous 
matter,  and  then  the  edges  should  be  brought  together  in  such  a 
way  as  shall  best  promote  a  speedy  and  perfect  union.  Sometimes, 
when  the  wound  is  slight,  the  surfaces  may  be  brought  together 
at  once.  In  other  and  more  severe  cases  it  is  well  ta  wait  till 
all  oozing  has  stopped,  for  the  eflTused  blood  is  apt  to  coagulate, 
and  act  as  a  foreign  body. 

What  means  are  we  to  use  for  securing  coaptation  ?  This  is 
a  very  important  question,  for  much  depends  upon  bringing  the 
surfaces  accurately  together,  and  keeping  them  in  this  position. 
We  are  often  able  to  effect  these  objects  by  very  simple  means — 
by  studying  the  position  of  the  patient,  by  applying  a  suitable 
bandage,  by  using  small  strips  of  plaster,  or  even  by  cover- 
ing the  line  of  incision  with  a  film  of  collodion,  or  of  Richardson's 
"  colloid  styptic." 

In  the  case  of  deep  incised  wounds,  such  as  may  be  inflicted 
on  the  thigh,  we  sometimes  require  a  bandage  which  shall 
draw  the  edges  together,  and  keep  them  in  that  position. 
A  uniting  bandage,  as  it  is  called,  may  be  made  by  taking 
a  piece  of  calico  of  suitable  width,  and  long  enough  to  go  fully 
twice  round  the  part.  Near  one  end  of  the  bandage  two  or  three 
parallel  slits  should  be  cut,  and  the  other  end  should  be  torn  into 
an  equal  number  of  tails.  When  the  bandage  has  to  be  applied 
it  should  be  folded  round  the  limb,  and  the  tails  passed  through 
the  corresponding  slits,  and  pinned.    As  the  ends  are  drawn  across 


o8 


INJURIES. 


Fie:.  26. 


^  a 

e 

a 

the  wouud  a  certain  degree  of  compression  is  exercised  upon  it, 
and  the  edges  are  hrought  together.  The  effect  of  the  bandage 
may  be  enhanced  by  laying  pads  of  lint  along  the  edges  of  the 
wound,  disposed  in  such  a  way  as  to  make  a  gentle  lateral  pres- 
sure upon  the  deeper  parts. 

Smaller  wounds  may  conveniently  be  brought  together  with 
adhesive  plaster.  This  may  be  done  in  various  ways.  Thus,  an 
oblong  opening  may  be  cut  near  one  end  of  a  suitable  strip  of 

diachylon,  while  another  piece  is  shaped 
in  the  manner  represented  in  Fig.  25, 
by  nicking  the  edges  and  folding  down 
the  plaster  so  as  to  form  a  tongue  which 
may  be  passed  through  the  correspond- 
ing opening,  and  drawn  tight  across  the  wound — in  fact,  it  is  not 

unlike  the  uniting  bandage  that  we 
liave  just  described.  Or  the  surgeon 
may  take  two  pieces  of  plaster  shaped 
something  like  the  letter  L,  and  place 
one  on  each  side  of  the  wound,  in 
the  way  represented  m  Fig.  26,  so 
'^  that  when  they  are  drawn  together 

a  may  come  to  c  and  h  to  d. 
If  more  than  this  is  necessary,  we  must  have  recourse  to 
stitches — sutures.  Sutures  are  made  of  various  m.aterials,  and 
are  applied  in  many  different  ways,  according  to  circumstances. 
Some  surgeons  prefer  hempen  thread  or  silk  ;  others  an  animal 
membrane,  such  as  catgut;  others,  again,  a  fine  wire.  The  ad- 
vantages claimed  for  the  latter  are  that  it  does  not  irritate  the 
tissues,  and  that  it  does  not  absorb  the  secretions.  The  catgut 
suture,  particularly  if  it  has  been  rendered  antiseptic,  is  much 
used  at  the  present  day.  It  is  soft  and  pliable ;  it  does  not 
harbour  putrefactive  secretions,  and  it  liquefies  after  a  short  time 
— the  knot  coming  away  without  any  pain  or  difficulty.  For  all 
ordinary  cases,  however,  a  hempen  or  silken  suture,  well  waxed, 
is  probably  as  good  as  any. 

The  needle,  armed  with  suitable  material,  should  be  passed 

through  the  whole  depth  of  the 
^ig-  27.  true  skin,  entering  and  emerg- 

ing at  a  short  distance  from  the 
line  of  incision.  The  thread,  gut, 
or  wire  is  then  to  be  drawn 
through,  and  knotted  or  twisted, 
so  as  to  keep  the  opposed  sur- 
faces in  their  proper  position. 
When  separate  sutures  are  introduced,  each  half  an  inch  or  an  inch 


WOUNDS. 


59 


Fig.  28. 


apart,  they  are  called  interrupted  (Fig.  27).  As  many  such 
stitches  are  to  be  inserted  as  are  necessary  to  keep  the  parts  in 
accurate  apposition — but  no  more.  Sometimes,  when  the  wound 
is  deep,  and  we  wish  to  make  sure  of  bringing  the  lower  part  of 
the  cut  surfaces  together,  a  pad  of  lint  may  be  laid  along  each  side 
of  the  incision,  in  addition  to  the  sutures,  and  pressure  made 
downwards  and  inwards  by  means  of  a  bandage. 

The  tivisted  suture  is  a  variety  of  the  interrupted.  It  is  made 
by  passing  a  hare-lip  pin  through  the  wound  which  we  wish  to 
unite,  and  then  twisting  a  silk  thread  firmly  over  it  in  the  form  of 
a  figure  of  8,  embracing  one  end  of  the  pin  in  each  loop  of  the  8. 
This  kind  of  suture  may  be  made  to  lay  hold  of  the  tissues  to 
almost  any  depth.  It  is  particularly  applicable  to  wounds  in  the 
face — as,  for  example,  those  made  in  the  operation  for  hare-lip. 

The  quilled  suture  (Fig.  28)  is  another  variety  of  the  inter- 
rupted. It  has  the  same  advantage  as  the  preceding — namely, 
that  it  brings  the  deep  surfaces  of  wounds  into 
apposition.  But  it  is  applicable  to  some  situa- 
tions— the  perineum,  for  example — where  hare- 
lip pins  would  be  inconvenient.  It  is  made  in 
this  way.  A  needle,  mounted  in  a  handle,  is 
armed  with  a  double  thread,  and  passed  deeply 
across  the  wound,  and  then  withdrawn,  leaving 
a  loop  at  one  side  and  two  ends  at  the  other. 
This  proceeding  is  repeated  as  often  as  the 
length  of  the  incision  may  require.  A  quill,  or 
a  piece  of  a  gum  catheter,  is  then  inserted 
through  the  whole  line  of  loops ;  the  threads 
are  drawn  tight;  and  the  ends  are  firmly  tied 
around  a  similar  piece  of  gum  catheter  on  the 
other  side  of  the  incision.  Lastly,  the  edges  of 
the  wound  are  united  by  simple  interrupted  sutures. 

The  continuous  or  Glover's  suture  is  chiefly  used  for  slight 
wounds  of  the  intestines.  Recently,  however,  it  has  been  employed 
to  close  external  wounds,  in  the  hope  of  bringing  about  more  per- 
fect contact,  and  more  speedy  union.  It  is  made  with  a  delicate 
needle  and  fine  thread — the  needle  passing  through  and  through, 
while  the  thread  goes  over  and  over,  the  two  edges  of  the  wound, 
like  the  seam  of  a  glove. 

Sutures  are  only  temporary  expedients.  With  rare  exceptions 
they  are  removed  in  the  course  of  from  twenty -four  hours  to  a  week. 
If  they  cause  great  irritation,  they  must  be  taken  away  at  once ; 
for  it  must  be  remembered  that  they  are  foreign  bodies,  and  may 
set  up  so  much  inflammation  as  to  prevent  union  by  adhesion 
from  taking  place  at  all. 


60  IN.TUEIES. 

Some  surgeons  object  altogether  to  the  use  of  sutures  in  wounds 
of  the  scalp,  on  the  ground  that  they  increase  the  tendency  to 
erysipelas.  But  practically  this  is  not  found  to  be  the  case,  and 
the  only  extra  caution  which  need  be  observed  is  not  to  pass  the 
needle  so  deep  as  to  penetrate  the  aponeurosis  of  the  occipito- 
frontalis  muscle. 

In  dealing  with  an  incised  wound  we  must  not  forget  the  con- 
stitutional treatment.  We  must  study  to  keep  the  inflammation 
within  the  limits  necessary  for  union  by  adhesion.  To  do  this  it 
may  sometimes  be  needful  to  reduce  the  patient  a  little  by  pur- 
gatives, salines,  and  a  spare  diet ;  sometimes  to  give  him  alcoholic 
stimulants  and  animal  food. 

If  the  conditions  of  the  wound  are  not  favourable  for  union  by 
adhesion,  the  edges  begin  to  gape,  and  a  discharge  of  thin  pus 
makes  its  appearance.  Suppuration  has  commenced.  The  sooner 
then  that  the  stitches — or  a  sufficient  number  of  them  to  give  a 
free  vent — are  removed  the  better,  for  we  must  now  treat  the 
wound  as  a  granulating  one,  and  be  contented  with  "  union  by 
the  second  intention,"  But  if,  after  a  time,  the  inflammation 
should  be  reduced  within  the  limits  that  are  compatible  with  the 
effusion  of  healthy  and  plastic  lymph,  we  may  again  bring  the 
granulating  surfaces  into  apposition,  and  endeavour  to  get  a 
secondary  union  bv  adhesion. 

Subcutaneous  wounds  may  be  considered  as  a  variety  of  the 
incised,  A  narrow-bladed  knife  is  passed  through  the  skin,  and 
then  the  tissues  are  divided  subcutaneously,  the  superficial  wound 
hardly  exceeding  the  breadth  of  the  blade  of  the  knife.  Tendons 
and  cicatricial  bands  are  often  divided  in  this  way  ;  and  recently 
Mr.  W.  Adams,  Mr.  L.  S.  Little,  and  others,  liave  applied  the  same 
method  to  sections  of  bone.  The  advantage  of  such  incisions 
consists  in  this,  that  no  air  is  admitted,  suppuration  does  not  take 
place,  and  the  blood  which  is  effused  is  absorbed,  as  in  the  case  of 
a  simple  bruise.  The  incision  in  the  skin  may  easily  be  closed  by 
a  strip  of  plaster,  or  by  a  pad  and  bandage. 

COSTTUSEB  AND  IiACERATSD  WOUXDS 

may  be  conveniently  considered  together. 

In  a  contused  wound  the  adjacent  tissues  are  bruised  or 
crushed.  In  a  lacerated  wound  the  edges  are  torn  and  ragged. 
These  two  conditions — bruising  and  tearing — often  go  together 
in  practice. 

In  a  lacerated  wound  there  is  little  to  fear  from  haemorrhage. 
Vessels  which  are  torn  across  soon  cease  to  bleed. 

However  slight  the  degree  of  contusion  or  laceration  may  be, 
it  is  likely  that  the  vitality  of  some  portion  of  the  tissues  will  be 


PUNCTURED  WOUNDS.  61 

destroyed.  If  so,  it  will  be  thrown  off  in  the  form  of  a  slough  ; 
suppuration  is  established  ;  union  by  primary  adhesion  is  out  of 
the  question.  The  extent  of  the  slough  will  depend  not  only 
upon  the  amount  of  bruising,  but  also  upon  the  nature  of  the 
tissue  that  is  injured.  The  scalp,  the  face,  the  hands,  and  other 
parts  which  are  very  vascular,  are  not  nearly  so  apt  to  slough  as 
parts  which  are  less  highly  supplied  with  blood. 

Erysipelas,  gangrene,  and  tetanus  are  the  evils  that  we  have 
chiefly  to  dread  in  wounds  of  this  description. 

In  the  treatment  of  contused  and  lacerated  wounds  our  first 
care  should  be  to  cleanse  the  part,  to  replace  the  tissues,  and  then 
to  perform  any  operation  that  may  be  necessary.  In  doing  this 
we  should  remove  as  little  as  possible.  A  very  slender  tongue  of 
skin  often  serves  to  maintain  vitality  in  apparently  hopeless  cases. 

We  should  endeavour  to  promote  the  separation  of  sloughs,  and 
to  moderate  the  suppuration,  so  that  there  may  be  as  little  loss  of 
substance  as  possible.  With  this  view  water-dressing  or  a  poultice 
should  be  applied,  and  subsequently  a  carbolic  acid  or  other  anti- 
septic lotion  (F.  12,  14).  Perhaps  some  of  the  other  means  which 
we  have  before  mentioned  in  speaking  of  inflammation  may  be 
required.  At  the  same  time  it  will  almost  always  be  necessary 
to  support  the  general  health. 

The  question  of  amputation  in  connexion  with  this  class  of 
injuries  is  often  a  difficult  one.  It  would  be  impossible  for  me  to 
discuss  it  fully  here.  All  I  can  do  is  to  mention  the  principal 
points  which  must  influence  the  surgeon  in  forming  his  opinion. 

If  part  of  a  limb  has  been  severed,  or  all  bat  severed,  from  the 
body,  an  operation  should  be  undertaken  with  the  view  of  making 
a  useful  stump. 

When  the  whole  substance  of  the  limb  has  been  crushed,  there 
can  be  no  doubt  that  an  amputation  should  be  performed. 

When  the  limb  has  been  much  lacerated,  the  bone  comminuted, 
or  I  he  main  arteries  torn  across,  amputation  will  generally  be  the 
wisest  course. 

When  one  of  the  large  joints  has  been  freely  opened  amputa- 
tion may  be  requisite.  If,  however,  the  case  at  ail  permits  of  it, 
an  effort  may  be  made  to  save  the  limb,  either  by  performing  a 
resection,  or  by  treating  the  wound  with  a  strictly  antiseptic 
dressing  or  with  ice-bags,  combined  with  absolute  rest. 

FUNCTUREB   "WOUXBS 

are  such  as  are  made  by  a  narrow  sharp-pointed  instrument — 
e.g.,  an  arrow,  a  dagger,  or  the  point  of  a  knife.  They  mar 
penetrate  to  any  depth,  and  are  often  accompanied  by  some 
degree  of  laceration.     They  are  dangerous ;  because  of  the  injury 


62  INJURIES. 

they  may  do  to  subjacent  organs  or  parts,  and  because  they  may 
be  followed  by  inflammation  in  the  deeper  portions  of  the  wound. 

Formerly  it  was  the  custom  at  once  to  dilate  all  punctured 
wounds,  and  to  convert  them  into  incised  wounds.  But  this  is 
not  done  now  except  under  special  circumstances — e.g.,  when  a 
large  artery  has  been  injured  and  must  be  tied,  or  a  piece  of  the 
weapon  remains  behind  and  cannot  otherwise  be  extracted.  In 
all  ordinary  cases  we  endeavour  by  the  pressure  of  pads  and  a 
bandage  to  bring  tbe  lower  parts  of  the  wound  into  apposition,  so 
as  to  get  it  to  unite  from  the  bottom  by  adhesive  inflammation. 
If  this  fails,  it  may  be  necessary  to  enlarge  the  opening,  so  as  to 
give  a  free  vent  to  the  pus ;  while  poultices  are  applied  to  promote 
the  separation  of  the  tissues  whose  vitality  has  been  destroyed. 
Subsequently  antiseptic  or  stimulating  lotions  may  be  used. 

The  most  frequent,  if  not  the  most  severe,  punctured  wounds 
which  are  met  with  in  civil  practice  in  this  country  are  those 
which  are  made  by  the  entrance  of  a  needle.  The  readiness  with 
which  needles  introduced  under  the  skin  bury  themselves  in  the 
tissues,  or  even  travel  to  distant  parts,  is  extraordinary.  The 
surgeon  should  therefore  be  on  his  guard,  and  not  undertake  an 
operation  unless  he  can  feel  the  needle,  or  is  satisfied  of  its  lying 
in  a  particular  spot.  If  he  has  sufficient  proof  of  its  presence,  he 
should  make  a  tolerably  free  incision  over  it,  and  remove  it  with  a 
fine  forceps.  Swain  recommends  that  a  flap  should  be  made  by  cut- 
ting from  within  outwards.  If  the  surgeon  cannot  assure  himself 
of  its  position,  the  best  plan  is  to  order  a  poultice,  and  to  keep  the 
part  at  rest.  By  this  means  the  superficial  tissues  will  be  softened, 
the  needle  will  make  its  way  in  the  direction  of  least  resistance — 
i.e.y  towards  the  surface — and  then  it  can  be  easily  removed. 

GUNSHOT  -WOUSTDS 

include  all  those  which  are  caused  directly  or  indirectly  by  the 
discharge  of  firearms,  by  powder,  wadding,  shot,  shell,  fragments 
of  stone,  splinters  of  wood,  &c. 

Such  injuries  are  always  more  or  less  contused  or  lacerated. 
The  bleeding  is  generally  slight;  unless  one  of  the  main  arteries 
is  divided,  or  a  vascular  organ,  such  as  the  lung,  has  been  pene- 
trated, there  is  not  much  danger  from  haemorrhage. 

Gunshot  wounds  vary  from  the  slightest  contusion  to  the  most 
frightful  laceration.  They  may  produce  but  little  uneasiness,  or 
they  may  cause  instant  death. 

When  the  wound  is  inflicted  by  a  round  ball,  discharged  from 
a  smooth-bore  weapon,  the  aperture  of  entry  is  smaller  and  more 
sharply  defined  than  the  aperture  of  exit.  Such  is  the  general 
rule.     When,  however,  the  firearm  is  discharged  at  a  very  short 


GUNSHOT  WOUNDS.  63 

distance  the  case  is  reversed,  and  the  aperture  of  entry  is  larger 
and  more  irregular  than  the  aperture  at  the  exit. 

The  wounds  made  by  conical  balls  fired  from  rifled  weapons 
vary  extremely  in  their  characters — from  a  simple  abrasion  to  a 
ragged  and  lacerated  wound.  They  are,  as  a  rule,  much  more 
dangerous  than  the  injuries  inflicted  by  round  shot. 

Gunshot  injuries  are  generally  accompanied  by  shock,  both 
physiciU  and  mental ;  the  measure  of  which  depends  chiefly  upon 
the  severity  of  the  wound.  It  is  the  greatest  when  the  superfi- 
cial wound  is  large,  when  much  blood  is  lost,  or  when  some 
internal  organ  of  vital  importance  is  afiected.  In  these  cases  it 
approaches  to  syncope ;  at  the  same  time  the  mental  depression  is 
so  great  as  to  fill  the  most  stout-hearted  with  alarm  and  despair. 

It  used  to  be  held  that  a  mere  "wind-contusion"  was  capable 
of  producing  a  fatal  result.  But  it  seems  certain  that  such  is  not 
the  case,  and  that  in  all  the  recorded  instances  there  must  have 
been  actual  contact,  though  the  skin  may  not  have  been  broken. 

Eound  bullets  are  very  easily  diverted  from  their  course.  A 
button,  a  bone,  even  the  thyroid  cartilage,  has  been  sufiicient  to 
change  their  direction.  Sometimes  they  have  made  a  circuit 
round  the  trunk,  and  presented  themselves  at  their  aperture  of 
entry.  Sometimes  they  have  gone  half  round  the  cranium,  so 
that  their  aperture  of  exit  was  exactly  opposite  their  aperture  of 
entry — making  it  appear  as  if  they  had  passed  through  the  head. 
At  other  times  they  have  followed  the  most  devious  courses, 
guided  from  point  to  point  by  the  obstacles  that  came  in  their 
way.  The  history  of  military  surgery  is  full  of  such  strange  and 
hair-breadth  escapes. 

At  a  very  short  distance  powder  alone  will  produce  a  ragged 
and  scorched  wound.  Wadding  will  penetrate  at  a  somewhat 
greater  range.  At  a  short  distance  small  shot  enter  in  a  com- 
pound mass,  making  a  wound  like  a  bullet.  At  a  greater  distance 
they  separate,  and  only  pepper  the  surface.  When  a  round  bullet 
enters  it  makes  a  clean-cut  track ;  but  it  may  inflict  a  severe 
bruise,  and  even  break  a  bone  without  penetrating  the  skin  at  all. 
The  following  case  shows  how  slight  a  bruise  may  give  rise  to  the 
most  serious  and  even  fatal  results  : — A  writer  in  the  "  Annals  of 
Military  and  Naval  Surgery  "  (1864)  says  :  "  To  show  the  effect 
of  being  hit  by  a  spent  ball,  or  one  that  has  lost  its  greatest  im- 
petus, I  may  mention  a  case  that  came  under  my  notice  when  a 
colonial  volunteer  was  standing  talking  in  a  group  of  his  com- 
rades, and  was  struck  by  a  ball  in  the  abdomen,  over  the  region 
of  the  bladder.  The  ball  fell  on  the  ground  at  his  feet  without 
either  injuring  his  clothes  or  even  marking  the  skin.  He  did 
not  feel  much  pain  at  the  time,  and  walked  to  the  hospital,  a 


64  INJUEIES. 

distance  of  two  miles,  with  the  ball  in  his  pocket,  without  feeling 
much  pain;  but  he  died  shortly  afterwards  from  peritonitis  and 
extensive  inflammation  of  the  bladder.  The  entire  surface  of  the 
abdomen  presented  the  appearance  of  a  severe  bruise  in  a  few 
hours  after  being  struck." 

The  old  round  bullet  was  much  more  apt  to  lodge  both  in  the 
soft  tissues  and  in  the  hard  than  the  conical  ball  of  modern 
warfare.  The  increased  force  with  which  the  rifle  bullet  is  pro- 
jected, as  well  as  the  rotatory  movement  which  is  imparted  to  it, 
cause  it  to  inflict  the  most  severe  and  dangerous  wounds.  Nothing 
is  capable  of  arresting  its  progress  :  it  splinters  bones,  and  tears 
its  way  through  the  flesh. 

Irregular  pieces  of  iron,  such  as  the  fragments  of  shells,  make 
very  ghastly  and  dtmgerous  wounds. 

The  smooth  round  bullet,  after  it  has  lodged,  may  become 
encysted,  and  remain  in  its  fibrous  envelope  for  the  rest  of  the 
patient's  life  without  giving  rise  to  much  inconvenience. 

Irregular  missiles  of  all  sorts  set  up  so  much  irritation  that 
they  cause  their  own  ejection  by  suppuration.  • 

Portions  of  dress,  accoutrements,  &c.,  are  apt  to  be  driven  into 
the  wound  by  the  bullet.  Sometimes  it  has  been  known  to  carry 
a  pouch  of  the  clothing  before  it ;  so  that  when  the  clothing  was 
removed,  the  bullet  was  withdrawn  along  with  it. 

In  a  gunshot  wound  bones  may  be  simply  broken,  or  the 
fracture  may  be  compound,  or  comminuted.  Again,  a  bone  may 
be  perforated,  or  the  bullet  may  be  arrested  and  lodge  in  it. 

When  a  bone  is  simply  bruised  without  being  broken,  the 
injury  may  be  more  serious  than  it  appears  at  first  sight,  giving 
rise  to  prolonged  inflammation  and  necrosis. 

It  is  impossible  to  estimate  the  extent  of  a  gunshot  wound 
until  the  sloughs  have  separated ;  and  even  then  there  may  be 
accidents  which  may  ai-ise  to  complicate  the  case — hsemorrhage, 
abscess,  gangrene,  erysipelas,  pyaemia,  tetanus,  non-union  of 
fracture,  or  necrosis.  These  are  some  of  the  conditions  which 
may  supervene,  and  which  render  the  prognosis  very  uncertain. 

Treatment. — Gunshot  wounds  are  to  be  treated  on  the  same 
general  principles  as  other  contused  and  lacerated  wounds.  The 
surgeon's  aim  should  be  to  arrest  haemorrhage,  to  remove  foreign 
bodies,  to  replace  the  tissues,  to  hasten  the  separation  of  sloughs, 
and  to  put  the  parts  in  the  most  ftwourable  position  for  union 
by  granulation. 

The  wound  should  not  be  enlarged,  unless  it  be  to  tie  a  bleed- 
ing vessel,  remove  a  foreign  body,  evacuate  matter,  or  for  some 
similar  object.  If  there  is  reason  to  think  that  a  foreign  body  is 
present  in  the  wound,  a  careful  examination  should  at  once  be 


GUNSHOT  WOUNDS.  65 

made  with  the  finger  or  with  a  probe ;  and  if  any  extraneous 
substance  is  detected,  it  sliould  be  extracted  with  the  bullet 
forceps  or  other  suitable  instrument.  The  patient's  position  should 
be  carefully  studied.  At  first,  cold  water  should  be  applied  to 
the  wound.  Afterwards,  poultices  will  probably  be  required. 
When  the  sloughs  have  separated  disinfectant  or  stimulating 
lotions  should  be  used,  as  the  case  may  demand,  and  the  part 
should  bo  supported  by  a  bandage.  Constitutionally  our  first 
object  is  to  rally  the  patient  from  the  shock  that  he  has  received 
at  the  time  of  the  injury.  This  we  do  by  stimulants  and 
restoratives.  There  are,  however,  cases  in  which  they  must  be 
given  with  great  caution,  and  where  the  state  of  collapse  is  even 
a  benefit ;  in  penetrating  wounds  of  the  lung,  for  example.  Our 
next  endeavour  is  to  allay  the  fever  which  accompanies  the 
process  of  suppuration.  Lastly,  we  have  to  support  the  strength 
during  repair,  to  guard  against  any  of  the  complications  which 
have  been  mentioned,  and  to  deal  with  them  promptly  if  they 
arise. 

G-unsJiot  tvounds  of  the  chest. — A  bullet  may  penetrate  the 
chest,  and  lodge  in  the  cavity  of  the  pleura.  It  may  there  become 
encysted,  and  give  rise  to  no  further  symptoms.  More  commonly 
it  enters  the  substance  of  the  lung — sometimes  lodging  there, 
sometimes  passing  quite  through. 

When  the  lung  has  been  wounded  there  is  generally  great 
collapse,  approaching  to  syncope ;  the  face  is  pale  and  anxious^ 
the  breathing  difficult.  Often  there  is  expectoration  of  frothy 
blood,  and  sometimes  the  edges  of  the  wound  are  emphysematous. 
When  the  bail  lodges  in  the  lung  the  prognosis  is  very  un- 
favourable. 

Treatment. — The  wound  should  be  examined  as  gently  as 
possible.  Any  foreign  body  that  can  be  felt  should  be  removed. 
When  there  is  no  counter-opening  the  bullet  may  sometimes  be 
found  lying  beneath  the  scapula.  The  patient  should  be  laid  in 
bed,  and  the  wound  lightly  covered  with  water-dressing,  but  no 
immediate  efibrt  should  be  made  to  counteract  the  state  of 
collapse. 

If  it  seems  probable  that  internal  haemorrhage  is  going  on  it 
has  been  recommended  to  bleed  the  patient  to  syncope,  in  the  hope 
of  promoting  the  formation  of  a  clot.  But  this  plan  of  treatment 
is  open  to  question.  If  outward  hsemorrhage  is  going  on  there 
will  be  no  necessity  for  venesection.  The  external  application  of 
cold,  or  the  internal  administration  of  styptics  (F.  29,  47)  will 
assist  in  arresting  the  flow  of  blood.  The  patient  should 
be  kept  perfectly  at  rest,  on  a  low  diet,  consisting  chiefly  of  cold 
milk  and  iced  drinks,   and   everything  should    be   done  which 


66  INJURIES. 

can  promote  the  healing  of  the  bullet  track.  With  this  view 
feverish  symptoms  must  be  allayed,  pain  mitigated,  and  sleep 
procured  (F.  7, 10,  53).  But  after  all  that  the  surgeon  can  do,  it  is 
only  too  probable  that  abscess,  or  empysema,  or  pneumonia,  will 
bring  the  case  to  a  fatal  issue. 

Gunshot  wounds  of  the  abdomen  are  very  fatal  in  their  results. 
As  we  have  seen,  even  a  slight  contusion,  which  appears  at  the 
time  insignificant,  may  give  rise  to  diflfuse  peritonitis  and  death. 

Flesh  wounds  of  this  region  are  still  more  dangerous.  They 
should  be  handled  with  great  gentleness  for  fear  of  opening  the 
peritoneal  cavity,  lightly  dressed,  and  treated  on  general 
principles. 

In  the  case  oi  penetrating  wounds,  if  the  viscera  escape  injury, 
as  they  sometimes  do,  still  there  is  the  risk  of  peritonitis.  But 
it  much  more  frequently  happens  that  the  viscera  are  implicated, 
and  then  the  danger  is  greatly  increased.  A  wound  of  the  solid 
viscera — e.g.,  the  liver,  spleen,  or  kidney — is  more  hazardous 
than  a  wound  of  one  of  the  hollow  viscera.  Again,  a  wound  of 
the  stomach  or  large  intestine  is  more  dangerous  than  a  wound 
of  the  small  intestines. 

The  chief  symptoms  are  great  collapse — which  often  terminates 
fatally — pain,  vomiting,  and  perhaps  melffina.  These  symptoms 
declare  themselves  at  once.  Subsequently  there  may  be 
peritonitis,  or  a  disturbance  of  the  special  function  of  the  wounded 
viscus.  It  seldom  happens  that  the  intestines  protrude  through 
the  wound  unless  it  is  of  large  extent. 

Treatment. — The  wound  should  be  carefully  but  gently  exa- 
mined. No  immediate  effort  should  be  made  to  arouse  the 
patient  from  the  state  of  collapse,  unless,  indeed,  it  threatens  to 
prove  fatal.  If  the  bowel  is  wounded  to  a  small  extent  only,  it 
is  better  not  to  attempt  to  sew  it  up.  The  protrusion  of  the 
mucous  membrane  will  probably  close  it  sufficiently  until  a  cover- 
ing of  lymph  has  been  formed.  If  the  rent  is  larger  it  should 
be  closed  with  a  continuous  suture  of  fine  silk  or  carbolized  catgut, 
and  the  bowel  returned ;  or  it  may  be  stitched  to  the  edges  of 
the  wound  and  treated  as  a  faecal  fistula.  The  exact  size  and 
situation  of  the  rent  must  determine  which  of  these  two  courses 
is  to  be  adopted. 

The  patient  should  be  kept  perfectly  at  rest,  on  very  low  diet, 
supplemented  by  nutritious  enemata,  and  opium  in  full  and 
repeated  doses  should  be  given. 

Question  of  amputation  in  gunshot  injuries  of  the  limbs. — 
Under  this  head  it  is  impossible  for  us  to  do  more  than  lay  down 
a  few  general  rules.  Each  case  has  its  own  peculiar  circum- 
stances, which  must  receive  special  consideration.     Moreover,  it 


rOISONED  WOUNDS.  67 

will  make  great  difference  whether  the  injury  occurs  in  civil  or 
military  practice.  Many  a  limb  has  been  saved  in  a  regular 
hospital  which  must  have  been  sacrificed  in  campaigning.  As  a 
general  rule  "conservative  surgery"  is  not  practicable  in  war- 
fare. 

Amputation  should  be  performed  under  the  following  circum- 
stances : — 

1.  When  part  of  a  limb  has  been  severed  from  the  body,  or 
hangs  only  by  the  integuments. 

2.  When  the  whole  substance  of  the  limb  has  been  crushed 
and  bruised  to  disorganization,  with  or  without  laceration  of 
the  skin. 

3.  When  a  large  mass  of  the  soft  tissues  has  been  carried  away, 
involving  important  vessels  and  nerves. 

4.  When  one  of  the  larger  joints  is  opened,  or  the  bones  which 
enter  into  its  formation  are  splintered. 

5.  When  there  is  a  severe  compound  fracture.  In  a  case  of 
compound  fracture  of  the  lower  end  of  the  femur  an  amputation 
may  be  performed.  But  when  the  injury  is  seated  at  the  upper 
end  of  the  bone  the  operation  is  so  uniformly  fatal  that  it  is 
perhaps  wiser  not  to  undertake  it. 

When  one  of  the  smaller  joints  is  injured  the  question  of 
excision  should  be  entertained ;  but  this  class  of  operations  is 
attended  with  great  difficulties  in  military  practice. 

Every  amputation  should  be  performed  as  far  from  the  trunk 
as  circumstances  will  permit,  for  the  higher  we  rise  on  the  limb 
the  greater  is  the  mortality. 

Supposing  the  surgeon  has  determined  to  amputate,  another 
question  arises.  When  should  the  operation  be  performed  ? 
Should  it  be  a  primary  amputation — i.e.,  an  amputation  per- 
formed within  forty-eight  hours  before  febrile  symptoms  have 
arisen,  or  should  it  be  a  secondary  amputation,  performed  after 
the  traumatic  fever  has  subsided  ?  Experience  has  decided  this 
question  in  favour  of  the  former ;  for  it  appears  that  primary 
amputations  are  not  nearly  so  fatal  as  secondary. 

POZSOXSD  WOTTNBS 

may  have  any  form  ;  they  maybe  incised,  lacerated,  or  punctured. 
Their  essential  character  is  that  through  them  a  poisonous  mate- 
rial is  introduced  into  the  blood,  which  may  affect  the  whole 
system,  and  even  produce  death. 

The  virus  may  be  either  a  healthy  secretion,  like  the  poison  of 
serpents,  or  a  morbid  product,  like  the  poison  of  hydrophobia. 

Wounds  poisoned  by  healthy  secretions. — It  is  seldom,  in  this 
country  at  any  rate,  that  the  stings  of  insects  lead  to  serious 

f2 


68  INJTJUIES. 

results.  When  such  a  case  is  brought  before  a  surgeon,  the  wound 
ought  to  be  carefully  examined  with  a  lens,  and  if  the  sting  can 
be  found,  it  should  be  extracted.  The  part  should  then  be 
frequently  bathed  with  an  alkaline  or  evaporating  lotion.  If  it 
is  the  tongue  or  the  fauces  that  are  stung,  active  measures  may 
be  required.  It  may  be  necessary  to  scarify  the  part,  or  to  open 
the  veins  beneath  the  tongue,  or  even  to  perform  tracheotomy  in 
order  to  prevent  suffocation.  But  the  symptoms  must  be  very 
urgent  indeed  to  warrant  the  surgeon  in  undertaking  this  opera- 
tion, because  the  inflammation  excited  by  such  an  injury,  though 
it  may  run  high,  is  generally  of  short  duration. 

The  bite  of  a  snake  is  a  formidable  thing  in  the  Tropics,  but 
not  so  in  England.  The  common  viper  is  the  only  poisonous 
snake  that  we  have  in  this  country,  and  his  venom  has  but  little 
effect  upon  healthy  and  vigorous  persons.  It  is  only  in  the  case 
of  the  very  old  or  the  very  young,  or  when  the  bite  has  been 
inflicted  on  a  critical  part — such  as  the  interior  of  the  mouth — 
that  active  local  measures  need  be  used.  In  most  instances  all 
that  is  wanted  is  a  restorative  to  support  the  patient  under  the 
alarm  which  he  is  apt  to  feel. 

In  warmer  climates  several  very  formidable  snakes  are  met 
with — e.g.,  the  rattlesnake  in  America,  the  puff-adder  in  Africa, 
and  the  Cobra-di-capello  in  India.  When  a  bite  has  been  in- 
flicted by  one  of  these  the  treatment  must  be  prompt  and  active. 
A  ligature  should  be  immediately  thrown  round  the  limb  above 
the  seat  of  injury,  to  obstruct  the  return  of  blood  to  the  heart. 
The  wound  should  then  be  thoroughly  cleansed  by  sucking,  or  by 
the  application  of  a  cupping-glass ;  or  its  surfaces  should  be 
destroyed  by  nitric  acid,  nitrate  of  silver,  or  the  actual  cautery. 
If  it  is  favourably  situated,  the  bite  may  be  excised.  At  the  same 
time  that  these  local  measures  are  adopted  stimulants  should  be 
freely  given  to  support  the  patient  and  to  prevent  the  collapse 
which  is  so  apt  to  follow  from  alarm  and  the  depressing  action 
of  the  venom.  Professor  Halford,  of  Melbourne,  has  recommended 
the  injection  of  ammonia  into  the  veins.  The  practice  has  been 
attended  by  success  in  his  hands,  and  is  worthy  of  a  further  trial 
{Brit.  Med.  Jour.,  Jan.  30th,  1869). 

Wounds  poisoned  hy  morbid  products. — Hydrophobia  is  caused 
by  the  bite  of  the  dog,  wolf,  fox,  and  some  other  animals,  when  in 
a  state  of  rabies.  Such  rabies  seems  to  occur  under  two  forms. 
Sometimes  the  animal  shows  unusual  activity,  sometimes  unusual 
depression.  In  either  case  the  bite  is  capable  of  producing  hydro- 
phobia. But  it  is  worthy  of  notice  that  of  those  who  are  bitten 
only  a  small  proportion  manifest  the  disease — about  one  in  twelve 
or  lifteen.     The  virus  requires  a  period  of  incubation,  and  seldom 


EQUINIA.  69 

shows  its  effect  for  a  month  or  longer.  Tlie  most  dangerous  bites 
are  those  on  the  hands,  face,  and  other  exposed  parts. 

The  premonitory  symptoms  of  hydrophobia  are  these  : — the 
wound  becomes  irritable,  painful,  and  discoloured.  Though  it  may 
have  healed,  it  sometimes  opens  again,  and  begins  to  discharge  an 
unhealthy  matter.  The  patient  becomes  uneasy,  restless  and 
feverish ;  fits  of  excitement  alternating  with  periods  of  depression. 

In  the  course  of  three  or  four  days  the  actual  symptoms  com- 
mence, and  no  doubt  remains  as  to  the  fearful  nature  of  the 
malady.  There  is  inability  to  swallow  fluids  in  consequence  of 
spasm  in  the  pharynx.  The  muscles  of  respiration  as  well  as 
those  of  deglutition,  are  thrown  into  painful  and  violent  con- 
tractions by  the  slightest  exciting  causes,  and  there  is  loud  and 
distressing  hiccup.  The  patient  is  usually  horror-struck.  Nothing 
can  exceed  his  alarm  and  despair.  He  is  quite  unable  to  sleep. 
His  eyes  are  wild  and  bloodshot ;  his.  breathing  difficult ;  his 
mouth  loaded  with  viscid  saliva,  which  froths  upon  his  lips,  and 
which  he  is  constantly  trying  to  expectorate.  He  may  die 
asphyxiated  in  one  of  the  attacks  of  dispncea,  or  he  may  sink  at 
the  end  of  a  few  days  from  exhaustion. 

Of  the  pathology  of  hydrophobia  we  know  nothing.  The  con- 
ditions which  induce  rabies  in  animals,  and  the  changes,  local  and 
constitutional,  which  take  place  in  the  patient  are  alike  involved 
in  mystery.  The  principal  morbid  appearance  that  has  been  met 
with  after  death  has  been  congestion  of  the  brain,  spinal  cord,  and 
their  membranes,  with  serous  eftusion. 

Treatment. — When  there  is  the  slightest  suspicion  of  danger 
the  bite  should  be  freely  excised  and  bleeding  promoted.  In 
situations  where  the  knife  cannot  be  used,  the  surfaces  of  the 
wound  should  be  thoroughly  touched  with  a  pencil  of  lunar  caustic, 
or  with  a  glass  rod  dipped  in  the  strong  nitric  acid. 

We  have  no  specific  for  hydrophobia ;  when  it  is  once 
established  all  that  can  be  done  is  to  support  the  patient  by 
careful  feeding,  and  to  palliate  the  symptoms  by  powerful  seda- 
tives and  narcotics.  Our  best  hope  of  mitigating  the  severity  of 
the  disease  lies  in  the  use  of  opium,  Indian  hemp,  chloroform, 
ice  to  the  spine,  or  the  subcutaneous  injection  of  morphia.  (F.  10.) 
At  the  same  time  everything  should  be  done  which  can  soothe  the 
patient  and  allay  his  irritability.  All  causes  of  excitement, 
mental  as  well  as  bodily,  should  be  carefully  removed.  But  it  is 
seldom  that  we  succeed  in  averting  the  fatal  issue. 

EQUZN-ZA. 

The  poison  of  equinia  is  generated  in  animals  of  the  horse  tribe. 
It  may  be  transmitted  to  a  man  either  by  inoculation,  through  a  sore. 


70  INJURIES. 

or  by  mere  contact  with  the  skin  or  mucosa  without  abrasion  of 
surface.  It  manifests  itself  under  two  forms — glanders  and 
farcy.  In  both  there  is  feverishness  with  glandular  enlarge- 
ments, and  the  formation  of  pustules  on  the  skin,  particularly 
about  the  face  and  in  the  neighbourhood  of  the  joints. 

The  most  characteristic  symptom  of  glanders  is  an  inflammation 
of  the  lining  membrane  of  the  nose.  An  offensive  discharge  mixed 
with  blood  pours  from  the  nostrils.  Sometimes  this  inflammation 
runs  so  high  as  to  cause  sloughing.  At  the  same  time  the  salivary 
glands  as  well  as  the  cervical  lymphatic  glands  become  swollen, 
tender,  and  prone  to  suppuration. 

In  farcy  the  subcutaneous  glands  throughout  the  body  become 
hard  and  painful,  constituting  what  are  known  as  "  farcy-buds." 

The  glandular  enlargements  in  equinia,  as  well  as  the  pustules, 
are  probably  due  to  the  deposition  of  a  material  analogous  to 
tubercle.  The  affection  of  the  Schneiderian  membrane  is  no  doubt 
of  the  same  kind.  This  is  borne  out  by  the  fact  that,  if  the 
patient  lives  long  enough,  there  is  always  some  consolidation  of 
the  lungs  with  circumscribed  patches  of  pneumonia. 

Each  variety  of  the  disease  may  run  an  acute  or  a  chronic 
course.  When  acute,  it  is  almost  certainly  fatal.  When  chronic, 
there  is  a  hope  of  recovery. 

The  treatment  of  equinia  must  consist  in  supporting  the  patient 
by  a  well  regulated  diet,  favourable  hygienic  conditions  and  tonic 
medicines,  while  the  pustules  and  sloughs  are  treated  on  general 
principles.  For  the  offensive  discharge  from  the  nose  the  nasal 
cavities  should  be  frequently  syringed  with  astringent  or  disin- 
fectant lotions. 

BzssECTZOM-  uvomrDS 

are  generally  free  from  danger ;  sometimes,  however,  they  give 
rise  to  the  most  serious  and  even  fatal  consequences.  Everything 
seems  to  depend  upon  the  health  of  the  person  who  is  wounded, 
and  the  nature  of  the  matter  which  is  inoculated. 

An  individual  whose  health  is  impaired  from  over  study, 
dissipation,  or  any  other  cause,  is  much  more  likely  to  suffer  than 
one  who  is  robust  and  in  good  condition. 

If  the  matter  is  inoculated  from  a  body  but  recently  dead,  it  is 
much  more  dangerous  than  if  it  is  taken  from  one  in  an  advanced 
stage  of  decomposition.  For  this  reason  wounds  received  in  the 
deadhouse  are  more  to  be  feared  than  those  which  are  met  with 
in  the  dissecting-room. 

The  matter  derived  from  different  dead  bodies  seems  to  vary 
much  in  its  poisonous  qualities.  Cceteris  paribus,  that  which  is 
drawn  from  the  bodies  of  those  who  Lave  died  of  erysipelas, 


MALIGNANT  PUSTULE.  71 

pyaemia,  peritonitis,  and  puerperal  fever  appears  to  be  much  the 
most  dangerous. 

In  a  severe  case  the  symptoms  are  local  irritation,  heat,  swelling, 
and  throbbing  pain.  Sometimes  a  pustule  forms  at  the  seat  of 
injury.  Soon  the  absorbents  inflame.  The  lymphatic  glands 
lecome  enlarged  and  tender,  suppuration  takes  place,  diffuse 
cjUular  inflammation  follows,  and  abscesses  form  in  various 
parts. 

These  symptoms  are  accompanied  by  a  high  degree  of  fever  of 
tte  asthenic  type,  and  tlie  patient  either  sinks  at  the  end  of  a  few 
days  or  weeks  from  exhaustion  of  the  vital  powers;  or,  if  he 
recovers,  it  is  only  after  a  tardy  and  prolonged  convalescence. 

Treatment. — The  first  thing  to  be  done  is  to  bind  a  ligature 
tightly  round  the  part  above  the  seat  of  injury.  The  wound  should 
then  be  washed  with  a  stream  of  cold  water,  and  afterwards 
sucked,  so  as,  if  possible,  to  get  rid  of  the  matter  altogether.  If 
it  seems  desirable  to  do  more  than  this,  the  wound  may  be 
touched  with  strong  nitric  or  pure  carbolic  acid.  If,  however,  not- 
withstanding these  precautions,  it  should  inflame,  poultices  must 
be  applied  at  once.  As  soon  as  the  lymphatic  glands  become  pain- 
ful, they  should  be  assiduously  fomented  ;  and  if  suppuration  takes 
place,  incisions  should  be  made  without  delay.  If  abscesses  form 
in  remote  parts,  they  should  be  opened  immediately. 

The  constitutional  treatment  consists  in  clearing  the  intestinal 
canal  by  a  purgative,  allaying  the  febrile  symptoms  by  salines, 
and  procuring  sleep  by  opium,  while  the  strength  is  upheld  by 
stimulants  and  a  nutritious  diet. 

iviAiiZCN.A.ia'T  pvsTiriiZ: 

{Charhori)\%  caused  by  a  poison  which  is  generated  in  horned  cattle. 
Of  the  "  bovine  disease"  which  gives  rise  to  the  virus  very  little  is 
known.  The  poison,  however,  may  be  transmitted  to  man  either 
by  inoculation  or  by  contagion.  Whether  it  can  be  introduced 
by  inhalation  or  by  eating  the  diseased  meat  is  uncertain.  In 
my  work  on  the  Diseases  of  the  Tongue,  I  have  alluded  to 
some  remarkable  cases  of  malignant  pustule  affecting  that 
organ. 

Symptoms. — A  dark  pustule  forms  on  the  affected  part,  bursts 
and  discharges  an  offensive  slough.  The  resulting  ulcer  spreads 
rapidly  by  phagedaenic  action.  This  local  inflammation  is  accom- 
panied by  fever  of  a  putrid  and  typhoid  character. 

The  treatment  consists  in  arresting  the  unhealthy  ulceration 
by  caustics,  favouring  the  elimination  of  the  poison  from  the 
system,  and  upholding  the  patient's  strength. 


72 


"WOTTN-BS  BIT  IRRITAITT  POXSOITS. 

Tlie  irritant  poisons,  externally  applied,  give  rise  to  injuries 
which  fall  under  the  care  of  the  surgeon. 

The  mineral  acids  rapidly  destroy  the  tissues  with  which  ther 
come  in  contact,  and  cause  extensive  wounds. 

The  injured  part  should  be  well  washed — first  with  warm 
water,  and  then  with  a  solution  of  carbonate  of  soda ;  after  tHs 
has  been  thoroughly  done  a  poultice  or  a  fomentation  should  "be 
applied. 

When  the  poisonous  agent  is  one  of  the  caustic  alkalies  the 
part  should  be  freely  bathed  with  a  weak  acid  solution — e.ff,, 
vinegar  and  water — and  then  poulticed. 

The  only  metallic  substance  which  we  need  mention  is  the 
nitrate  of  silver.  It  is  readily  decomposed  by  a  solution  of  com- 
mon salt. 

BFFECTS  OF  HSAT. 

Heat,  communicated  from  solid  bodies,  gives  rise  to  Burns; 
from  fluid  or  gaseous  bodies  it  occasions  Scalds. 

Injuries  caused  by  the  application  of  heat  are  attended  by 
various  dangers. 

(a)  They  are  accompanied  by  a  shock,  which  sometimes  ap- 
proaches to  syncope,  and  may  even  prove  fatal. 
{h)  The  period  of  depression  is  followed  by  proportionate  reac- 
tion, with  inflammatory  symptoms, 
(c)  During  this  second  stage  internal  organs  are  apt  to  become 
affected,  particularly  the  lungs  and  the  small  intestines. 
{d)  If  the  patient  survive  these  dangers,  he  has  still  to  go 
through  the  exhausting  processes   of  suppuration  and 
repair. 
Injuries  caused  by  heat  are  divided  by  Dupuytren  into  six  de- 
grees.    His  classification — which  is  one  of  great  practical  value 
— is  now  generally  adopted  :— 

1.  Where  the  cuticle  is  merely  scorched. 

2.  Where  the  cuticle  is  raised  in  blisters. 

3.  Where  the  cutis  vera  is  more  or  less  destroyed. 

4'.  Where    the  injury   extends  through  the  cuticle  and  true 
skin,  and  reaches  the  sub-cutaneous  cellular  tissue. 

5.  Where  the  muscles  and  fascia?  are  involved. 

6.  Where  the  whole  thickness  of  the  limb  is  implicated. 

In  practice  we  generally  find  that  several  of  these  degrees  go 
together.  A  case  in  which  the  muscles  are  touched  will  probably 
show  the  milder  forms  of  injury  as  well. 


EFFECTS  OF  HEAT.  73 

Mr.  Curling  has  drawn  attention  to  an  interesting  point  con- 
nected with  extensive  burns.  He  has  observed  that  they  often 
seem  to  occasion  ulcers  in  the  duodenum ;  and  he  supposes  that 
Brunner's  glands,  in  order  to  compensate  for  the  functions  of  the 
skin,  take  on  an  increased  and  even  excessive  action.  This  point 
well  deserves  further  inquiry,  and  it  should  make  the  surgeon 
attentive  to  the  slightest  indications  of  gastric  or  intestinal 
irritation,  as  shown  by  vomiting  or  purging. 

The  prognosis  in  burns  or  scalds  will  depend  in  a  great 
measure  upon  the  amount  of  surface  that  is  involved;  both 
because  the  skin  is  a  complex  tissue,  highly  supplied  with  nerves, 
and  also  because,  when  its  functions  are  arrested  to  any  consider- 
able extent,  internal  organs  are  very  apt  to  become  congested 
and  inflamed.  Speaking  generally,  when  a  sixth  part  of  the  surface 
of  the  body  is  affected,  the  prognosis  is  unfavourable.  But  the 
age  of  the  patient,  the  situation  of  the  injury,  and  the  depth  to 
which  the  destructive  action  has  penetrated,  are  points  which 
must  not  be  overlooked  in  forming  an  opinion  on  the  case  and 
its  probable  issue.  The  cuticle  is  speedily  replaced ;  but  the 
cutis  vera  is  never  reproduced ;  and  wherever  it  has  been  de- 
stroyed, a  cicatrix  will  be  left. 

The  old,  the  young,  and  those  in  impaired  health  are  par- 
ticularly liable  to  suffer  from  the  shock  of  a  severe  burn  or 
scald. 

The  situation  of  the  injury  is  very  important.  If  it  is  on  the 
head  it  may  give  rise  to  inflammation  of  the  brain  or  its  mem- 
branes. If  it  is  on  the  chest,  pneumonia  or  bi-onchitis  is  likely 
to  ensue.  If  a  child  has  scalded  the  back  of  its  mouth  by 
attempting  to  drink  out  of  the  kettle,  the  injury  may  cause 
speedy  death  by  inflammatory  closure  of  the  rima  glottidis. 

The  treatment  of  burns  and  scalds  is  partly  constitutional  and 
partly  local. 

Constitutional  treatment. — The  first  thing  to  be  done  is  to 
rally  the  patient  from  the  state  of  shock,  and  to  bring  about 
reaction.  With  this  view  the  patient  should  be  placed  in  bed 
with  a  hot-water  bottle  to  his  feet,  and  stimulants  should  be  given 
at  once — a  glass  of  warm  brandy  and  water  or  a  cup  of  hot  tea, 
for  example.  If  the  depression  is  accompanied  by  much  anxiety 
or  alarm,  sedatives,  such  as  the  tincture  of  hyoscyamus  or  the 
vinum  opii,  may  be  combined  with  the  restoratives.  Death  not 
unfrequently  takes  place  during  this  first  period  of  the  case. 

When  reaction  has  begun,  our  aim  must  be  to  keep  it  within 
moderate  limits — to  restrain  the  inflammatory  action.  To  this 
end  perfect  quietness  and  repose  should  be  enforced,  and  mild 
purgatives  or  salines  should  be  given  from  time  to  time  as  occa- 


74  INJURIES. 

sion  requires.  The  strength  must  be  upheld  by  stimulants  and 
by  a  nutritious  diet.  Pain  must  be  mitigated  and  sleep  procured 
by  the  cautious  use  of  sedatives  and  narcotics. 

This  is  the  most  fatal  stage  in  the  course  of  a  severe  burn,  and 
the  surgeon  ought  to  be  on  the  watch  for  the  earliest  signs  of 
complications — meningitis,  bronchitis,  pneumonia,  albuminuria,  or 
intestinal  ulcers. 

When  the  inflammatory  symptoms  have  subsided  the  patient 
will  still  have  to  pass  through  a  period  of  suppuration.  If  the 
injury  has  been  of  considerable  extent,  his  strength  will,  even 
under  the  most  favourable  circumstances,  be  severely  taxed ;  but 
if  hectic  should  supervene,  it  will  go  hard  with  his  life.  To 
uphold  the  vital  powers,  by  cordials,  tonics,  and  good  food,  is  the 
great  aim  of  constitutional  treatment  while  suppuration  con- 
tinues. 

Local  treatment. — The  patient's  clothes  should  be  gently  and 
carefully  removed,  being  cut  wherever  they  are  adherent  to  the 
body.  If  blisters  have  formed  they  should  be  pricked  and  the 
serum  let  out,  but  the  cuticle  should  on  no  account  be  detached. 

In  all  injuries  from  burns  or  scalds  it  has  been  found  that  the 
sufferer  experiences  great  relief  when  the  surface  is  coated  with  an 
unirritatinar  substance  which  excludes  the  air,  and  maintains  an 
equable  temperature.  This  principle  may  be  carried  out  in  a 
variety  of  ways.  Some  surgeons  dust  flour,  or  starch,  or  gum 
tragacanth  over  the  affected  surface.  Others  prefer  to  varnish 
the  part  with  a  mixture  of  collodion  and  castor-oil,  two  measures 
of  the  former  to  one  of  the  latter  (F.  73,  74).  Others  employ  a 
weak  turpentine  lotion  or  ointment.  "  Carron-oil "  (equal  parts 
of  lime-water  and  linseed-oil)  enjoys  a  widespread  reputation. 
But  whatever  application  is  used,  a  smooth  and  thick  layer  of 
cotton-wool  should  be  laid  over  it,  and  retained  by  a  bandage ; 
for  it  is  not  merely  an  equable  temperature,  but  a  Mgli  one  as 
well,  that  seems  to  allay  the  scorching  pain.  When  once  the 
dressing  has  been  applied  it  should  be  changed  as  seldom  as  pos- 
sible— indeed,  only  where  the  discharges  render  such  change 
absolutely  necessary.  In  this  way  the  repair  goes  on  most 
favourably,  and  the  patient  is  saved  from  much  pain  and  distress. 

If  the  burn  is  of  the  fourth  degree,  or  more,  this  treatment 
should  be  followed  for  a  few  days,  and  then  poultices  should  be 
applied.  When  the  sloughs  have  separated,  the  wound  should  be 
treated  on  general  principles  with  water-dressing,  or  stimulating 
or  astringent  lotions,  as  the  case  may  require.  An  ointment  of 
chalk,  or  a  weak  solution  of  carbolic  acid  (F.  12)  forms  an  excellent 
dressing  when  the  suppuration  is  very  profuse. 

When  cicatrization  commences,  the  surgeon  must  bear  in  mind 


EFFECTS  OF  COLD.  75 

the  great  tendency  there  is  to  contraction,  and  do  all  in  his  power 

— by  studying  the  position  of  the  patient,  by  bandages,  by  me- 
chanical appliances — to  prevent  it.  But  notwithstanding  all  his 
efforts,  more  or  less  contraction  is  sure  to  take  place.  Some- 
times this  gives  rise  to  the  most  frightful  disfigurement  and  dis- 
tortion. Can  anything  be  done  to  prevent  or  to  remedy  these 
evils  ?  The  character  of  the  cicatrix  may  perhaps  be  improved 
by  adopting  Reverdin's  method  of  making  skin-grafts.  But  if, 
notwithstanding,  an  unsightly  or  inconvenient  cicatrix  is  left, 
nothing  short  of  an  operation  has  any  permanent  value.  In 
planning  sucb  operations  the  surgeon  has  great  scope  for  his 
ingenuity.  Sometimes  the  cicatrix  may  be  divided  subcutaneously, 
and  stretched  by  mechanical  means.  Sometimes  a  flap  of  skin 
may  be  partially  dissected  from  the  adjacent  parts  and  turned 
across  a  corresponding  surface  which  has  been  laid  bare  on  the 
cicatrix.  Or  a  portion  of  skin  may  be  similarly  dissected  from  a 
distant  part,  the  cicatrix  being  brought  to  it,  and  firmly  bound 
in  that  position  till  union  has  taken  place — constituting  a  true 
Tagliacotian  operation.  Sometimes  the  best  we  can  do  is  an 
amputation. 

EFFECTS  OF  COIiB. 

When  severe  cold  is  applied  to  the  body  it  depresses  the  action 
of  the  heart,  and  paralyses  the  nervous  force.  These  eflects  are 
most  visible  in  parts  where  the  circulation  is  naturally  feeble,  as 
the  nose,  ears,  feet,  &c.  The  arterial  supply  is  diminished,  while 
the  blood  is  retarded  in  its  passage  through  the  veins.  Hence  the 
part  loses  its  natural  colour,  and  becomes  purple  or  blue.  Sensa- 
tion is  almost  goue,  vitality  is  reduced  to  a  very  low  ebb — in  fact 
there  is  fi'osf -bite.  Still,  however,  the  circulation  may  be  restored 
by  judicious  measures. 

But  if  the  degree  of  cold  is  very  intense,  or  if  exposure  to  it  is 
long  continued,  vitality  is  wholly  destroyed,  mortification  takes 
place,  and  restoration  is  impossible.  This  untoward  result  is 
particularly  apt  to  occur  in  those  whose  vigour  is  already  impaired 
by  want  of  sufficient  food  and  clothing. 

It  should  be  noted  that  one  effect  of  extreme  cold  is  to  produce 
an  overpowering  sense  of  drowsiness,  but  to  yield  to  the  inclina- 
tion, and  to  lie  down  to  sleep  under  such  circumstances,  is  almost 
certain  death. 

Treatment. — When  a  part  is  frost-bitten,  our  object  should  be 
to  bring  about  vert/  gradual  reaction.  The  patient  should  be 
placed  in  a  room  without  a  fire,  and  the  part  must  be  gently  but 
continuously  rubbed  with  snow  or  other  cold  applications.  Heat 
should  on  no  account  be  applied,  as  it  is  very  apt  to  produce 


76  INJURIES. 

gangrenfi.  The  temperature  must  be  restored  from  within,  not 
from  without.  The  object  is  to  make  the  circulation  advance 
from  the  deeper  parts  to  the  more  superficial.  Stimulants — a 
little  warm  coffee  or  brandy  and  water,  for  example — may  be 
given  from  time  to  time  in  small  quantities. 

When  reaction  has  taken  place,  and  the  circulation  has  been 
restored,  it  may  be  evident  that  some  portion  of  the  tissues  has 
mortified.  If  this  is  the  case,  poultices  should  be  used  to  hasten 
the  separation  of  the  sloughs,  and  the  wound  which  remains 
should  be  treated  on  general  principles. 

Chilblains  arise  from  a  mild  degree  of  frost-bite,  and,  when 
circulation  is  restored,  an  almost  intolerable  itching  and  tingling 
is  experienced,  and  the  part  is  red  and  swollen.  They  are  fre- 
quently induced  by  wearing  boots  that  are  too  thin  for  the  season, 
and  then  sitting  before  the  fire  with  damp  or  wet  feet.  When 
the  inflammation  thus  set  up  runs  on  to  ulceration  it  produces 
what  is  called  a  hrolcen  chilblain. 

Chilblains  are  most  often  seen  in  children,  but  they  may  occur 
also  in  adults  who  have  a  languid  circulation,  or  who  are  in  weak 
health. 

Treatment. — When  persons  are  subject  to  chilblains  they  should 
be  careful  to  change  their  stockings  after  exercise,  as  the  damp- 
ness caused  by  confined  perspiration  is  very  apt  to  induce  them. 
When  inflammation  has  commenced,  the  affected  part  should  be 
painted  with  tincture  of  iodine,  or  with  a  mixture  of  camphor 
and  zinc  in  glycerine,  or  bathed  with  a  lotion  of  Goulard 
water  and  laudanum  ;  or  rubbed  with  compound  camphor,  iodine, 
or  turpentine  liniment;  or  with  iodine  or  calamine  ointment. 
If  the  chilblain  breaks,  it  must  be  treated  on  general  principles, 
first  with  poultices  or  water-dressing,  and  afterwards  with  stimu- 
lating applications.  In  any  case  it  will  be  necessary  to  give 
proper  attention  to  the  patient's  food  and  clothing,  and  also  to 
prescribe  tonics,  more  particularly  the  preparations  of  iron. 

SUSPEITDBS    AZa-ZMATZOM'. 

The  suspension  of  animation  may  commence  either  at  the 
heart  or  at  the  lungs.  It  may  be  due  either  to  synco'pe  or  to 
a/pncza. 

Syncope  {fainting)  depends  upon  an  irregular  and  deficient 
supply  of  blood  to  the  brain.  It  may  arise  from  hajmorrhage, 
debility,  emotion,  impure  air,  or  other  causes. 

The  symptoms  are  giddiness,  swimming  in  the  head,  insensi- 
bility, and  loss  of  consciousness.  The  patient  lies  still  and 
motionless.  Tlie  lips  are  white ;  the  surface  of  the  body  blanched 
and  cold.     The  breathing  is  slow  and  shallow.      The  pulse  feeble 


SUSPENDED  ANIMATION.  77 

and  intermittent.     Death  may  result  from  the  entire  stoppage  of 
the  heart's  action. 

The  treatment  consists  in  laying  the  patient  flat  on  a  bed  or 
on  the  floor,  and  even  depressing  his  head  slightly  by  placing  a 
pillow  underneath  his  back.  His  face  and  chest  should  be 
sprinkled  with  cold  water,  strong  smelling  salts  should  be  held  to 
his  nose,  and  warmth  and  friction  applied  to  the  surface  of  the 
body.  As  soon  as  he  begins  to  rally,  a  little  stimulant — brandy, 
or  sal  volatile,  with  water — should  be  given. 

Apnoea  (or,  as  it  used  to  be  called,  asphyxia)  occurs  when  the 
supply  of  air  to  the  lungs  is  cut  off.  This  may  arise  in 
various  ways — by  hanging,  drowning,  iipmersion  in  irrespirable 
gases,  &c. 

The  blood  in  the  lungs  is  not  aerated;  dark-coloured  blood 
circulates  through  the  brain,  giving  rise  to  coma  or  convulsions, 
and  after  the  lapse  of  three  or  four  minutes  the  heart's  action 
ceases  altogether. 

Treatment. — The  cause  should,  if  possible,  be  removed.  Any  liga- 
ture that  may  be  round  the  patient's  neck,  any  pressure  that  may 
be  preventing  the  expansion  of  the  chest,  should  be  taken  away. 

If  respiration  is  still  going  on,  the  surface  of  the  body  should  be 
rubbed,  hot-water  bottles  applied  to  the  epigastrium  and  feet, 
and  ammonia  held  to  the  nostrils.  When  sensibility  and  con- 
sciousness begin  to  return,  a  cordial  should  be  given. 

If  breathing  has  ceased,  but  the  heart  still  beats,  artificial 
respiration  should  be  commenced  without  delay  (see  Artificial 
Respiration),  while  at  the  same  time  the  stimulating  measures 
mentioned  in  the  foregoing  paragraph  should  also  be  employed. 

If  the  heart's  action  has  ceased  as  well  as  the  breathing,  gal- 
vanism should  be  used  in  conjunction  with  artificial  respiration. 
When  the  case  has  gone  as  fur  as  this,  there  is  but  a  very  small 
hope  of  restoring  animation. 

In  cases  of  hanging,  death  may  take  place  by  dislocation  of  the 
cervical  vertebrae,  or  by  congestion  of  the  brain  and  apoplexy,  as 
well  as  by  apnoea  from  pressure  upon  the  trachea. 

In  cases  of  drowning  the  patient  should  of  course  be  removed 
from  the  water,  and  carried  to  the  nearest  shelter.  He  should  be 
at  once  placed  in  a  hot  bath  or  wrapped  in  a  warm  blanket,  with 
hot-water  bottles  beside  him ;  the  surface  of  the  body  rubbed, 
and  smelling  salts  applied  to  his  nostrils.  At  the  same  time 
artificial  respiration  should  be  practised.  As  the  water  does  not 
find  entrance  into  the  lungs,  it  is  not  necessary  to  invert  the 
patient  before  courmencing  the  artificial  respiration  as  was  for- 
merly done.  All  that  is  needed  is  to  remove  the  mucus  from  the 
mouth,  and  to  draw  the  tongue  well  forward. 


78 


ARTZFZCXAXi  RESPIBATZOir 

may  be  practised  in  several  ways,  but  the  principle  is  the  same  in 
all.  Our  aim  is,  first,  to  expand  the  thoracic  cavity,  and  then  to 
contract  it  in  imitation  of  the  natural  movements  of  inspiration 
and  expiration.  Whatever  plan  is  adopted  the  steps  of  the  pro- 
cess should  be  repeated  about  fifteen  times  a  minute,  steadily  and 
with  regularity,  and  persevered  in  as  long  as  there  remains  the 
slightest  hope  of  restoring  animation. 

Dr.  Marshall  Hall's  method  consists  in  laying  the  patient  on 
his  face  on  the  floor,  or  on  a  table,  and  then  turning  him  over  on 
his  back.  By  this  means  the  weight  of  the  body  compresses  the 
chest  while  it  expands  again  by  the  natural  elasticity  of  the 
ribs. 

Dr.  Sylvester's  method  is  easier  of  application,  and  has  now 
been  generally  adopted  by  the  Royal  Humane  Society.  The  pa- 
tient should  be  laid  on  his  back,  and  then  both  his  arms  should  be 
raised  above  his  head,  held  there  for  a  second  or  two,  and  brought 
down  again  on  the  sides  of  the  chest  with  some  degree  of  pressure. 
After  the  lapse  of  two  seconds  the  process  should  be  repeated. 
Thus  the  muscles  of  respiration  attached  to  the  humerus  serve 
to  dilate  the  thorax,  while  it  is  compressed  by  the  adduction  of  the 
arms.  This  plan  is  as  efficient  as  any  other ;  it  is  simpler,  and  it 
has  the  additional  advantage  of  appearing  less  rough  in  practice. 


PART   III. 

CONSTITUTIONAL  EFFECTS 

OP 

SURGICAL  DISEASES  AND  INJURIES. 


SHOCK.— COI.I.il.PSE, 

When  a  person  receives  a  severe  injury  his  nervous  system  sus- 
tains a  shock.  This  shock  manifests  itself  in  a  variety  of  ways, 
but  especially  by  its  effect  upon  the  heart.  The  supply  of  nerve- 
force  Ls  disturbed,  or  even  stopped  altogether.  The  heart  may 
suddenly  cease  to  beat,  or  its  action  may  gradually  fail. 

The  symptoms  vary  widely  in  degree.  To  take  a  typical 
case  : — The  patient  lies  in  a  helpless,  half-conscious  state.  When 
addressed,  he  answers  in  an  incoherent  way.  He  is  cold  and 
shivering,  the  surface  of  the  body  being  blanched  and  bedewed 
with  clammy  moisture.  The  pulse  is  quick,  small,  and  almost 
imperceptible  J  the  breathing  irregular  and  sighing;  the  fea- 
tures pinched ;  the  expression  anxious ;  the  eyes  vacant ;  the 
sphincters  relaxed.  The  temperature,  if  tested  by  the  ther- 
mometer, is  found  to  be  lowered.  Sometimes  convulsions  ensue, 
especially  in  children.  Sometimes  there  is  vomiting,  which  is 
rather  a  good  sign,  and  often  indicates  the  approach  of  reaction. 

These  symptoms  may  be  so  severe  as  to  produce  complete  col- 
lapse, followed  by  death  from  syncope  in  the  course  of  a  few 
minutes  or  hours.  This  fatal  result  is  most  likely  to  happen 
when  the  injury  is  very  extensive,  when  the  chest  or  abdomen  is 
penetrated,  or  when  some  internal  organ  of  primary  importance 
is  involved. 

It  is  interesting  to  observe  that  the  shock  may  be  communi- 
cated to  the  nervous  system  through  the  mind,  as  well  as  through 
the  body.  Persons  have  been  killed  by  a  fright,  or  by  the 
receipt  of  distressing  or  alarming  news  j  and  in  every  case  the 


80  CONSTITUTIONAL  EFFECTS. 

mental  constitution  of  the  patient  will  influence  the  degree  of 
prostration.  In  persons  of  a  lively  and  excitable  temperament 
the  effects  of  shock  are  likely  to  he  the  most  severe. 

Treatment, — When  the  shock  is  chiefly  mental,  a  few  reassur- 
ing words,  a  cordial,  and  rest  in  bed,  with  an  extra  blanket,  and 
a  hot-water  bottle  to  the  feet,  will  suffice  to  restore  the  patient. 

In  the  milder  examples  of  shock  from  injury  the  same  treat- 
ment will  generally  be  found  enough. 

If  the  case  is  more  severe,  the  patient  should  be  laid  in  bed  with 
his  head  rather  low.  Warm  flannels,  hot-water  bottles,  and  friction 
should  be  applied  to  the  surface  of  the  body.  Stimulants  should 
be  given  gradually  and  with  caution.  If  the  collapse  continues, 
and  the  patient  has  not  lost  much  blood  from  the  injury,  Mr. 
Savory  recommends  that  the  jugular  vein  should  be  opened  to 
relieve  the  over-distended  heart,  and  thus  facilitate  its  contraction. 
No  operation  of  magnitude,  which  can  be  deferred,  should  be 
undertaken  during  this  stage.  If  there  is  a  wound,  it  should  be 
washed,  and  treated  in  the  ordinary  way. 

In  extreme  cases  we  must  have  recourse  to  stimulating  ene- 
mata,  rubifacients,  blisters,  sinapisms,  or  galvanism  to  restore  the 
natui'al  functions.  Stimulants — ammonia  to  the  nostrils,  or  a  few 
drops  of  brandy  placed  within  the  lips — are  often  of  great  value. 
Of  course  if  the  patient  is  in  an  insensible  state,  fluids  ought  not 
to  be  given  in  any  quantity,  for  fear  they  pass  into  the  larynx. 

As  the  sufferer  recovers  from  the  shock,  reaction  takes  place, 
and  our  aim  must  be  to  keep  it  within  the  limits  consistent  with 
health.  In  mild  cases  it  is  easy  enough  to  do  this  by  keeping 
the  patient  quiet,  restricting  his  diet,  and  acting  upon  the 
bowels.  During  the  period  of  reaction  any  operation  which  is 
necessary  may  be  performed,  and  if  aether  or  chloroform  are 
administered,  they  may  have  a  stimulating  effect,  and  thus  tend 
to  support  the  patient.  But  all  severe  cases  will  be  followed  by 
more  or  less  fever. 

SURGZCAIi  OR  TRAUMATIC  FEVER 

is  the  name  given  to  the  general  febrile  state  which  is  apt  to  follow 
injuries  or  operations.  It  is  probably  due  in  some  measure  to 
shock,  but  in  a  still  greater  degree  to  the  absorption  of  morbid 
fluids  from  the  blood.  It  ought,  therefore,  to  be  regarded  as  a 
septicamic  disease. 

The  nature  of  such  fever  varies  with  the  degree  of  injury,  the 
particular  part  affected,  and  the  constitution  and  habits  of  the 
patient. 

If  he  is  robust  and  vigorous,  the  inflammatory  symptoms  will 
be  of  the  sthenic  kind.     There  will  be  a  full  and  quick  pulse,  a 


SURGICAL  OR  TRAUMATIC  FEVER.  81 

hot  skin,  a  high  temperature,  a  flushed  face,  suffused  and  blood- 
shot eyes,  and  great  thirst. 

If  delirium  (traumatic  delirium)  comes  on,  as  it  often  does, 
especially  in  those  who  have  been  accustomed  to  take  large  quan- 
tities of  alcohol,  it  is  furious  in  its  character.  The  patient  is  un- 
governable, talks  loudly,  and  is  under  the  influence  of  delusions. 
Sometimes  he  is  inclined  to  be  merry,  but  more  often  he  is  angry. 
He  tosses  himself  in  bed,  is  always  wanting  to  get  up,  and  does 
not  seem  to  feel  any  pain  from  the  injury,  however  severe  it 
may  be. 

The  treatment  of  this  form  of  traumatic  fever  and  delirium 
must  be  actively  antiphlogistic.  Venesection,  leeches,  and  ice  to 
the  head,  purging,  and  low  diet — these  are  the  only  remedies  that 
hold  out  a  hope.  Opium  is  almost  useless,  and  may  even  do  harm. 
If  it  is  given  at  all,  it  should  be  combined  with  tartar  emetic,  as 
recommended  by  Dr.  Graves.     (F.  39.) 

If,  on  the  other  hand,  the  patient  is  broken  in  health  or  of  a 
feeble  constitution,  the  symptoms  will  be  of  the  asthenic  or 
irritative  type — the  pulse  quick  and  small,  the  tongue  brown, 
the  skin  pale  and  clammy,  the  features  pinched,  and  the  expression 
anxious. 

If  delirium  ensues,  it  is  of  the  low  muttering  kind ;  or  else  it 
is  busy,  meddling,  and  suspicious,  like  delirium  tremens. 

Treatment. — The  bowels  should  be  relieved,  and  then  opium 
should  be  given  in  full  doses,  and  repeated  every  three  hours,  until 
sleep  is  induced.  It  will  generally  be  found  advisable  to  combine 
the  opium  with  stimulants,  and  to  give  it  in  brandy  or  in  stout,  or 
in  whatever  the  patient  has  been  accustomed  to  drink.  At  the 
same  time  he  should  have  plenty  of  plain,  nutritious  food. 

In  all  cases  of  traumatic  delirium  the  patient  will  have  to  be 
restrained  so  as  to  prevent  his  getting  out  of  bed.  If  possible, 
this  should  be  done  by  persuasion,  management,  skilful  nursing, 
and  gentle  force.  If  more  than  this  is  required  it  will  be  neces- 
sary to  put  on  a  strait-waistcoat.  Such  a  waistcoat  is  made  of 
strong  cotton  cloth  or  of  ticking,  and  extends  from  the  root  of  the 
neck  to  the  waist.  It  has  no  opening  in  front,  but  at  the  back 
it  is  fastened  with  tapes.  The  sleeves  are  long,  so  as  to  extend 
some  little  distance  beyond  the  hands,  and  closed  at  the  extremi- 
ties. A  cord  is  generally  tied  round  them  below  the  hand,  and 
carried  down  to  the  foot  of  the  bed,  so  that  the  patient  is  obliged 
to  keep  his  arms  by  his  sides ;  or  else  they  are  crossed  over  his 
chest,  and  secured  in  that  position.  The  waistcoat  is  usually  fur- 
nished with  shoulder-straps,  through  which  a  belt  may  be  passed 
in  order  to  restrain  the  movements  of  the  patient's  body. 

We  have  described  extreme  cases  as  types  of  the  two  forms  ot 

a 


82 


CONSTITUTIONAL  EFFECTS. 


traumatic  fever,  but  in  practice  they  are  often  found  more  or  less 
blended. 

In  all  cases  of  surgical  fever  the  clinical  thermometer  ought  to 
be  regularly  employed.  Any  sudden  alteration  in  the  tempera- 
ture bodes  ill  for  the  patient.  If  it  is  in  the  upward  direction, 
it  shows  an  increase  in  the  feverish  symptoms ;  if  in  the 
downward  direction,  a  collapse  of  the  patient's  strength.  The 
annexed  chart  (Fig.  29)  affords  a  good  example  of  the  value  of 

Fig.  29. 


Thermometric  Chart. 

exact  thermometric  records.  It  was  kindly  furnished  by  Mr. 
Barwell.  The  patient  was  a  young  man,  aged  17,  whose  thigh 
was  amputated  in  Charing  Cross  Hospital  on  April  3rd,  1879,  on 
account  of  a  myeloid  sarcoma  of  the  femur.  Both  the  operation 
and  the  subsequent  dressings  were  done  with  strict  antiseptic 
precautions.  A  drainage  tube  was  left  in  the  wound.  At  the 
first  dressing,  on  April  5th,  ( X )  everything  was  normal ;  at  the 
second  dressing,  on  April  7th,  (  X  )ashealinghadmadegreat  progress 
and  as  there  was  but  little  discharge,  the  whole  of  the  drainage  tube 
was  removed,  except  about  three  inches.  It  will  be  seen  that 
from  this  time  the  temperature  gradually  rose  till  the  10th,  (*)  when 
the  stump  was  again  dressed.  On  this  occasion  the  drainage  tube 
was  missing.  A  careful  search  was  made,  and  it  was  found  deep 
down  in  the  stump  close  to  the  bone.  Probably  it  had  slipped  in 
at  the  date  of  the  second  dressing.  It  was  at  once  removed,  and 
the  temperature  gradually  fell  to  the  normal  point. 

All  injuries  which  have  been  attended  by  much  shock  or  which 
have  been  followed  by  severe  traumatic  fever,  are  apt  permanently 
to  weaken  the  nervous  system  of  the  patient.     Sometimes  this 


HECTIC  FEVER.  83 

change  shows  itself  in  his  temper  and  disposition  ;  sometimes  in 
his  bodily  health.  In  such  persons  disease  is  lighted  up  by  a 
slight  cause ;  and  they  not  unfrequently  become  chronic  invalids, 
or  die  suddenly. 

HSCTZC  FEVER, 

"When  suppuration  is  very  profuse  or  long-continued,  or  attended 
by  much  destruction  of  tissue,  it  gives  rise  to  a  febrile  state, 
known  as  hectic.  It  is  important  to  observe  that  this  condition 
does  not  declare  itself  as  long  as  the  pus  is  pent  up  in  a  cavity — 
e.g.,  in  a  psoas  abscess. 

The  si/mptoms  are  in  many  respects  those  of  asthenic  fever,  but 
with  some  peculiar  features.  Hectic  is  marked  by  periodic  remis- 
sions and  exacerbations.  The  exacerbations,  which  are  often 
accompanied  by  rigors,  take  place  towards  night,  while  the  remis- 
sions occur  in  the  morning.  After  the  paroxysm  has  reached  its 
height,  it  commonly  terminates  in  profuse  sweating,  with  great 
exhaustion.  The  pulse  is  quick,  soft,  and  easily  excited.  The 
tongue  is  covered  with  white  fur  in  the  centre,  while  the  tip  and 
edges  are  unnaturally  clean  and  red.  The  skin  is  at  one  time 
hot  and  dry,  at  another  soft  and  moist.  The  temperature  rises. 
The  urine  is  turbid  and  offensive.  Occasionally  there  is  diarrhcea. 
The  appetite  is  good ;  sometimes  it  is  excessive.  The  eyes  are 
brilliant;  the  cheeks  flushed.  The  strength  fails,  while  the 
emaciation  increases. 

The  mental  phenomena  are  hardly  less  characteristic  than  the 
bodily.  The  patient  is  easily  depressed,  but  more  easily  excited, 
his  mind  is  buoyant  and  hopeful,  and,  as  soon  as  he  is  relieved 
from  his  present  distress,  he  is  sanguine  of  recovery. 

Treatment. — Hectic  is  a  fever  of  irritation  and  debility,  and 
the  treatment  which  it  requires  is  essentially  soothing  and  tonic. 
The  patient  should  be  removed  from  everything  that  can  excite 
him,  and  placed  in  the  most  favourable  hygienic  conditions. 
With  this  view  he  should  have  plenty  of  fresh  air.  If  possible, 
he  should  be  taken  to  the  sea-coast — such  a  resort  being  selected 
as  is  not  too  keen  and  stimulating.  His  diet  should  be  liberal 
and  generous,  and  should  include  a  large  proportion  of  animal 
food.  If  his  strength  permits,  he  should  take  moderate  exercise, 
short  of  fatigue.  If  walking  is  out  of  the  question,  he  should 
go  out  in  a  carriage  or  Bath-chair.  In  any  case  he  should  be  as 
much  in  the  open  air  as  possible.  The  secretions  should  be  regu- 
lated, while  such  medicines  are  given  as  cod-liver  oil,  arsenic, 
quinine,  and  the  preparations  of  iron.  The  mineral  acids 
are  particularly  useful,  both  as  tonics  and  to  check  the  pro- 
fuse   sweating.      The    diarrhcea,    which    is    so    apt    to    arise, 

a2 


84  CONSTITUTIONAL   EFFECTS. 

must  be  treated  by  astringents  and  sedatives.  Hot  sponging 
and  rapid  drying  is  sometimes  very  refreshing  to  the  patient. 

Of  course,  every  local  means  must  be  employed,  including  any 
operation  that  may  be  desirable,  and  the  various  antiseptic 
dressings,  which  can  limit  the  suppuration,  and  bring  about  a 
healthy  condition  of  the  wound,  which  is  the  cause  of  the 
hectic. 

ERYSXPEIiAS 

is  the  name  given  to  a  constitutional  disease  of  the  inflammatory 
kind,  which  is  caused  by  a  specific  poison,  and  which  commonly 
manifests  itself  by  certain  local  symptoms.  The  constitutional 
disorder  is  always  present;  the  local  phenomena  admit  of  some 
variation,  and  may  even  be  altogether  absent. 

The  fever  which  attends  erysipelas  is  of  the  asthenic  kind. 
The  disease  may  safely  be  regarded  as  one  of  debility.  There  is 
shivering  and  nausea ;  a  quick,  weak  pulse ;  a  brown  tongue ;  a 
hot,  dry  skin;  and  a  tendency  to  low  muttering  delirium.  At 
the  same  time  it  is  no  uncommon  thing  to  see  the  brain,  the 
lungs,  or  the  alimentary  canal  involved  in  the  inflammatory 
process.  There  may  be  encephalitis,  or  pneumonia,  or  bronchitis, 
or  diarrhoea,  or  vomiting. 

When  erysipelas  shows  itself  locally,  it  is  by  an  unhealthy 
inflammation  which  has  a  remarkable  tendency  to  spread.  The 
lymph  which  is  poured  out  is  of  the  aplastic,  corpuscular  kind, 
and  forms  no  barrier  to  the  progress  of  the  disease.  This  extends 
chiefly  by  continuity  along  the  same  plane  of  tissue.  Its  favourite 
seats  are  the  free  surfaces,  such  as  the  skin,  the  mucous  mem- 
branes, and  the  inner  coats  of  arteries  and  veins ;  but  it  also 
affects  the  deep  layers  of  cellular  tissues. 

Erysipelas  is  broadly  divided  into  idiopathic  and  traumatic. 

Of  the  essential  nature  of  the  poison  of  erysipelas  we  know 
nothing.  When  the  disease  arises  spontaneously,  it  may  be  said 
to  depend  upon  a  want  of  proper  attention  to  the  laws  of  health. 
Thus  there  is  a  predisposition  to  it  when  the  system  is  disordered 
from  living  too  high,  or  living  too  low;  from  intemperance; 
from  insufficient  clothing  or  exercise ;  from  a  want  of  cleanliness 
and  fresh  aii*,  or  from  any  other  similar  cause.  The  same  may 
be  said  also  of  persons  who  are  labouring  under  any  disease 
which  affects  the  purity  of  the  blood,  as  albuminuria  or  diabetes. 

The  changes  of  the  weather,  and  the  alternation  of  the 
seasons  have  some  effect  in  favouring  the  development  of  the 
disease. 

Wounds  are  the  most  frequent  exciting  causes  of  erysipelas. 
It  behoves  the  surgeon,  therefore,  to  beware  how  he  undertakes 


ERYSIPELAS.  85 

an  operation  when  the  disease  is  epidemic.  Those  wounds  are 
likely  to  be  attended  with  the  most  serious  consequences  in  which 
the  deep  planes  of  cellular  tissue  are  exposed. 

The  disease  may  easily  be  produced,  at  least  in  hospitals,  by 
over-crowding,  and  a  want  of  proper  cleanliness  and  ventilation ; 
and,  when  once  it  has  been  set  up,  it  is  highly  infectious.  It  is, 
therefore,  of  the  greatest  importance  that  a  patient  affected  with 
erysipelas  should  be  isolated,  and  that  the  utmost  care  should  be 
taken  by  personal  cleanliness  on  the  part  of  the  attendants,  and 
by  the  free  use  of  disinfectants  to  prevent  it  from  spreading. 

The  best  classification  of  erysipelas  is  into  (1)  cutaneous ;  (2) 
ceUulo-cutaneous  ;  and  (3)  cellular. 

1.  The  cutaneous  is  the  mildest  form  of  the  disease.  It  extends 
only  to  the  true  skin.  The  surface  becomes  of  a  bright  rose 
colour,  whicli  disappears  on  pressure,  and  usually  fades  away  at  the 
edges  into  the  healthy  skin.  The  part  is  dry,  hot,  swollen,  hard, 
and  sometimes  oedematous;  and  there  is  pain  of  a  smarting 
character. 

When  erysipelas  arises  spontaneously  without  a  wound  it  gene- 
rally attacks  the  face ;  but  it  may  show  itself  anywhere.  Some- 
times it  suddenly  leaves  one  part  and  appears  in  another. 
(Metastasis.)  This  erratic  form  of  the  disease  always  indicates 
great  debility,  and  is  accompanied  by  considerable  risk,  inasmuch 
as  it  is  apt  to  attack  the  fauces,  or  other  important  parts.  Hip- 
pocrates long  ago  observed  that  when  erysipelas  fixes  upon  a  par- 
ticular part  of  the  body  it  is  more  formidable  in  appearance  than 
in  reality,  and  that  the  disease  is  attended  by  most  danger  when 
it  leaves  an  external  part  and  is  determined  inwardly  (Syd.  Soc. 
Translation,  i.  401). 

2.  CeUulo-cutaneous  (or  phlegmonous)  erysipelas  extends 
through  the  skin  to  the  subjacent  cellular  tissue.  When  once 
inflammation  has  been  lighted  up  in  a  layer  of  areolar  tissue  it 
runs  on  rapidly  to  suppuration  and  sloughing. 

The  local  phenomena  are  much  the  same  as  in  the  former  case, 
only  they  are  more  intense.  The  tint  of  surface  is  deeper  and 
more  fiery,  the  skin  is  harder  and  more  brawny,  the  swelling  is 
much  greater,  while  the  cuticle  is  raised  in  unsightly  blisters. 
After  about  a  week,  these  symptoms  undergo  a  change.  Some- 
times that  change  is  a  favourable  one,  and  resolution  takes  place. 
But  much  more  frequently  it  is  an  unfavourable  one.  The  part 
becomes  soft  and  doughy.  The  surface  loses  its  uniform  colour, 
and  becomes  mottled.  It  is  then  evident  that  suppuration  has 
occurred,  and  that  sloughing  is  imminent.  "WTien  an  extensive 
surface  is  affected,  or  when  the  patient  is  feeble  or  out  of  condi- 
tion, the  danger  is  great.     When  the  disease  attacks  the  face  and 


86  CONSTITUTIONAL  EFFECTS. 

head,  as  it  not  unfrequently  does,  the  aspect  of  the  case  is  alarm- 
ing, and  there  is  considerable  risk,  lest  the  membranes  of  the  brain 
should  be  affected.  At  the  best,  recovery  will  be  tedious,  and  it 
is  highly  probable  that  some  impairment  of  tissue,  or  of  function, 
will  remain  for  years. 

3.  The  cellular  variety  of  erysipelas  {cellulitis)  is  the  most 
severe  and  the  most  dangerous.  The  inflammation  attacks  the 
planes  of  cellular  tissue,  diffuses  itself  rapidly  along  them,  and 
leads  to  the  most  destructive  suppuration  and  sloughing.  Some- 
times it  is  the  more  superficial  layers  which  are  affected,  e.g.,  that 
which  lies  immediately  beneath  the  skin;  sometimes  it  is  the 
deeper  layers,  e.g.,  those  which  divide  the  muscles  or  envelop  the 
bladder. 

In  any  case  the  symptoms  come  on  apace  and  run  high.  There 
is  great  pain  and  swelling.  The  part  becomes  of  a  dusky  purple 
colour,  hard  and  tense,  and  the  skin  is  oedematous.  In  two  or 
three  days  these  symptoms  alter.  There  are  rigors.  Suppura- 
tion has  begun.  The  parts  become  boggy  from  infiltration  of  pus, 
and  mottled  from  the  approach  of  gangrene.  Sloughing  takes 
place  rapidly  and  extensively,  leading  in  most  cases  to  a  fatal 
issue  in  the  course  of  a  week. 

The  constitutional  symptoms  which  attend  these  different  forms 
of  erysipelas  are  the  same  in  kind,  though  they  vary  in  degree. 

If  the  inflammation  has  a  sthentic  character  at  the  outset,  it 
rapidly  degenerates.  The  typical  erysipelatous  fever  is  of  the 
low  asthenic  kind.  The  pulse  is  quick  and  weak,  the  skin  dry 
and  pmigent,  the  temperature  high,  the  tongue  furred  and  brown, 
with  a  tendency  to  muttering  delirium.  Frequently  there  is 
diarrhoea.  In  an  uncomplicated  case  it  is  death  from  exhaustion 
that  the  surgeon  has  to  guard  against. 

The  access  of  suppuration  will  be  marked  by  rigors ;  and  when 
gangrene  commences,  there  will  be  a  sudden  depression  and 
prostration  of  the  vital  powers,  which  will  probably  be  indicated 
by  a  corresponding  decrease  of  the  animal  heat. 

In  all  the  more  severe  cases  it  is,  as  we  have  said,  most  likely 
that  some  of  the  internal  organs  will  be  secondarily  affected. 
There  will  be  encephalitis,  or  bronchitis,  or  pneumonia,  &c. 

The  prognosis  in  cases  of  erysipelas  depends  chiefly  upon  the 
variety  that  we  have  to  deal  with,  the  seat  of  the  disease,  and  the 
constitution  and  habits  of  the  patient.  If  he  is  the  subject  of 
chronic  disease  of  any  internal  organ — more  particularly  of  the 
kidneys — it  will  add  very  much  to  the  danger  of  the  case. 

The  treatment  of  cutaneous  erysipelas  is  partly  constitutional 
and  partly  local. 

In  the  constitutional  treatment  the  first  thing  to  be  done  is  to 


ERYSIPELAS.  87 

clear  the  primce  via  by  an  emetic  or  a  purgative,  or  both.  If 
the  inflammatory  symptoms  run  high,  a  mildly  antiphlogistic 
plan  may  be  followed,  by  limiting  the  patient  to  a  fluid  diet,  and 
promoting  the  action  of  the  skin,  kidneys,  and  bowels.  It  must 
not  be  forgotten,  however,  that  though  at  the  outset  the  inflam- 
mation may  be  sthenic,  it  will  ere  long  in  all  probability  become 
asthenic.  Soon  stimulants  and  tonics — the  preparations  of 
ammonia  and  iron  (F.  34,  35,  47),  and  a  light  but  generous  diet, 
with  a  fair  allowance  of  brandy,  port  wine,  or  egg-flip  (F.  100) 
— will  be  required  to  support  the  failing  strength.  In  many  cases 
it  is  necessary  to  pursue  this  method  from  the  first.  Large 
and  frequent  doses  of  the  tinct.  ferri  perchloridi  have  sometimes 
been  followed  by  very  marked  benefit. 

Local  treatment. — In  every  case  the  part  should  have  perfect 
rest ;  and,  if  possible,  it  should  be  elevated,  while  fomentations — 
plain  or  medicated — are  diligently  used ;  and  if  the  fomentations 
are  covered  with  oiled  silk  or  waterproof  cloth,  they  will  retain 
the  heat  and  moisture  for  a  long  time.  Cold  applications  should 
be  avoided  :  they  are  apt  to  produce  metastasis,  which  is  very 
undesirable.  The  surface  should  be  dusted  with  flour  or  starch, 
or  painted  with  a  mixture  of  collodion  and  oil  (F.  73),  so  as  to 
exclude  the  air  and  keep  up  an  equable  temperature.  These  are 
excellent  applications,  and  very  grateful  to  the  feelings  of  the 
patient.  Some  surgeons  prefer  astringent  lotions  (F.  15, 16, 23). 
These  may  be  used  warm  or  tepid.  In  erratic  cases  blisters  are 
often  beneficial,  and  tend  to  fix  the  disease  to  one  spot.  When 
there  is  much  tension,  small  punctures  should  be  made  in  the 
skin  with  the  point  of  a  lancet — the  number  varying  according 
to  the  extent  of  surface  aflected.  In  this  way  a  little  blood 
and  serum  escape,  and  the  pressure  is  relieved.  Sometimes  an 
attempt  is  made  to  limit  the  inflammation  by  a  boundary  line  of 
lunar  caustic :  but  the  success  which  has  attended  this  practice  is 
hardly  sufficient  to  justify  it. 

After  the  acute  symptoms  have  disappeared,  a  bandage  should 
be  employed  in  order  to  restore  the  healthy  condition  of  the 
tissues;  and  the  part  should  be  regularly  rubbed  with  soap  lini- 
ment or  camphorated  oil.  By  this  means  the  stiff'ness  resulting 
from  eff'usion  will  be  removed. 

Treatment  of  the  cellulo-cutaneotcs  erysipelas. — The  constitu- 
tional treatment  of  this  variety  is  much  the  same  as  that  of  the 
cutaneous  erysipelas.  But  as  the  disease  is  more  formidable,  the 
patient  must  be  watched  more  narrowly,  and  the  tonic  remedies 
pushed  further,  if  need  be. 

The  local  treatment  does  not  differ  in  its  earlier  stages  from 
that  which  has  been  described   above.      As  soon  as  the   skin 


88  CONSTITUTIONAL  EFFECTS. 

becomes  tense,  limited  incisions  should  be  made  in  it,  and  when 
matter  has  formed,  it  must  be  let  out  without  delay. 

This  variety  of  the  disease  is  apt  to  be  followed  by  troublesome 
sequelse,  such  as  solid  oedema,  contracted  cicatrices,  sinuses  (con- 
nected perhaps  with  dead  bone),  &c. 

The  treatment  of  cellular  erysifelas  is  only  an  advance  upon 
that  which  we  have  described  as  suitable  to  the  cellulo-cutaneous 
variety. 

Stimulants  will  probably  have  to  be  given  both  more  freely 
and  at  an  earlier  date.  The  surgeon  should  be  on  the  watch  for 
abscesses,  and  open  them  as  soon  as  possible.  The  clinical  ther- 
mometer will  give  him  a  hint  when  suppuration  is  taking 
place. 

There  are  some  situations  in  which  erysipelas  is  particularly 
apt  to  occur,  and  where,  from  local  or  other  conditions,  it  deserves 
special  notice. 

Cellulo-cutaneous  (phlegmonous)  erysipelas  of  the  scalp  is 
often  seen  in  persons  who  are  enfeebled  by  age,  or  by  any  other 
cause.  If  the  disease  extends  to  the  sub-aponeurotic  plane  of 
cellular  tissues,  then,  on  the  one  hand,  the  occipito-frontalis 
muscle  may  slough,  while,  on  the  other,  the  inflammation  may  be 
communicated  to  the  brain  or  its  membranes.  These  disastrous 
consequences  seldom  occur  in  idiopathic  cases,  but  they  are 
common  after  wounds. 

Special  treatment. — The  head  must  be  shaved.  If  the  surface 
is  doughy,  and  there  is  reason  to  think  that  suppuration  has  taken 
place  in  the  sub-aponeurotic  cellular  tissues,  free  incisions  must  at 
once  be  made  down  to  the  bone,  in  a  direction  radiating  from  the 
vertex. 

Erysipelas  is  not  confined  to  the  external  parts  of  the  body. 
It  may  affect  the  mucous  or  serous  membranes,  or  the  lining  of 
arteries,  veins,  or  lymphatics.  The  general  character  and  ten- 
dency of  the  disease  is  essentially  the  same  as  when  it  attacks  the 
skin  or  cellular  tissue. 

Erysipelas  of  the  fauces  may  arise  spontaneously,  or  as  a  con- 
sequence of  the  disease  in  some  other  part.  In  addition  to  the 
ordinary  local  symptoms — redness,  swelling,  &c.,  which  manifest 
themselves  upon  the  soft  palate,  uvula,  and  fauces — the  voice  and 
breathing  are  generally  more  or  less  affected.  The  disease  is 
always  an  alarming  one,  and  calls  for  active  treatment.  If  the 
inflammation  spreads  to  the  lining  membrane  of  the  larynx,  the 
case  is  almost  hopeless. 

Treatment. — Tlie  parts  should  be  painted  with  a  strong  solu- 
tion of  nitrate  of  silver — 30  or  40  grains  to  the  ounce  of  distilled 
water — the  patient  should  breathe  a  warm  moist  atmosphere,  he 


PYEMIA.  89 

should  steam  his  throat  from  time  to  time,  and  make  frequent  use 
of  stimulating,  astringent,  or  disinfecting  gai-gles.  (F.  3,  4.)  If 
it  is  apparent  from  the  increasing  dyspnoea,  hoarse  cough,  and 
tenderness  about  the  neck,  that  the  inflammation  is  extending  to 
the  larynx,  the  question  of  laryngotomy  or  tracheotomy  will  have 
to  be  considered,  and  that  without  delay. 

The  difficulty  of  breathing  and  swallowing  which  accompanies 
this  disease  renders  it  a  peculiarly  exhausting  one.  The  treat- 
ment must,  therefore,  be  of  a  supporting  and  stimulating  kind 
from  the  first. 

Erysipelas  of  serous  membranes. — Among  serous  membranes 
the  arachnoid  and  the  peritoneum  are  those  which  are  most  often 
attacked  by  erysipelatous  inflammation.  In  either  case  the 
disease  generally  follows  an  injury,  or  an  operation,  or  erysipelas 
of  some  contiguous  part.  Under  any  circumstances  it  is  extremely 
fatal.  The  treatment  must  be  conducted  on  those  general  prin- 
ciples which  have  already  been  indicated. 

PYJEMZA 

is  the  name  given  to  a  disease  which  is  nearly  related  to  the 
worst  forms  of  surgical  fever  and  erysipelas,  and  which  manifests 
itself  by  well-marked  constitutional  phenomena  of  a  febrile  kind. 

It  is  always  preceded  by  suppuration,  and  it  leads  to  the  forma- 
tion of  abscesses  in  difierent  parts  of  the  body.  Hence  it  has  been 
supposed  to  depend  upon  the  admixture  of  pus  with  the  blood. 
But  this  theory  is  scarcely  tenable,  for — 1st.  How,  it  may  be 
asked,  does  the  pus  effect  an  entrance  into  the  circulation  ?  2nd. 
It  has  been  proved  by  experiment  that  pus  may  be  mixed  with 
the  blood  without  producing  pysemia.  3rd.  Though  sometimes, 
on  microscopic  examination,  the  blood  seems  to  contain  pus 
globules,  it  is  much  more  probable  that  they  are  in  reality  white 
blood  corpuscles. 

On  the  whole  it  appears  most  probable  that  the  pysemic  fever 
is  generated  by  a  poison  which  is  absorbed  from  the  suppurating 
surface,  but  which  is  much  more  subtle  and  delicate  in  its  nature 
than  pus.  Hence  the  disease  is  now  often  spoken  of  as  ichorcemia 
or  septiccemia — putrid  infection  of  the  blood.  And  thus  it  is 
linked  to  the  large  class  of  cases  which  are  included  under  the 
term  "  blood-poisoning,"  many  of  which  arise  without  any  wound 
or  any  suppuration. 

Two  other  points  are  worthy  of  notice  which  are  common  to 
pyaemia  and  many  other  cases  of  blood-poisoning.  (1)  The  white 
blood  corpuscles  are  increased  in  number :  there  is  leucocytosis  : 
and  if  the  patient  survives  the  attack  it  may  be  months  or  even 
years  before  the  proper  quality  of  the  blood  is  restored.   (2)  There 


90  CONSTITUTIONAL  EFFECTS. 

is  a  tendency  to  phlebitis  and  the  formation  of  blood  clots.     In  this 
way  sudden  and  alarming  complications  may  arise  at  any  time. 

When  a  person  is  about  to  be  attacked  by  pyaemia,  the  wound 
usually  becomes  dry  and  unhealthy.  The  pus  which  is  secreted 
is  scanty  and  thin.  At  the  same  time  there  is  increased  frequency 
of  the  pulse  and  breathing.  The  temperature  rises,  and  the 
patient  has  a  rigor,  more  or  less  distinct.  This  is  soon  followed 
by  a  copious  perspiration,  and  coincidently  the  temperature 
falls. 

WTien  the  disease  is  fully  established  the  complexion  is  sallow 
or  leaden.  The  eyes  sunken.  The  features  pinched.  The  tongue 
dry  and  brown.  The  pulse  quick  and  weak.  The  respiration 
hurried.  The  breath  has  a  faint  sweetish  hay-hke  odour.  The 
skin  is  moist,  and,  after  a  well-marked  rigor,  it  is  bathed  in  sweat. 
There  are  occasional  shiverings,  and  wandering  pains  are  felt  in 
various  parts.  With  all  this  there  is  great  prostration,  rapid 
wasting,  and  a  tendency  to  delirium.  The  urine  often  contains 
albumen. 

The  secondary  abscesses  that  are  apt  to  form  ai'e  usually  met 
with  in  internal  organs,  particularly  in  the  lungs  and  liver,  or  in 
the  neighbourhood  of  joints;  but  they  may  appear  almost  anywhere. 
When  they  are  situated  in  internal  organs  the  disease  generally 
runs  a  short  and  fatal  course ;  but  when  they  are  in  the  neigh- 
bourhood of  joints,  or  among  the  muscles,  it  may  last  for  weeks  or 
months.  In  these  protracted  cases  the  patient  may  either  sink 
from  exhaustion,  or  he  may  recover  with  more  or  less  impairment 
of  the  structure  or  function  of  the  affected  part. 

When  the  pyaemia  has  taken  its  origin  from  a  wound  which 
is  discharging/cB^Jc^  pus,  the  disease  is  usually  particularly  virulent. 

Treatment. — As  pysemia  is  promoted  by  a  want  of  fresh  air,  by 
overcrowding,  and  by  unfavourable  hygienic  conditions,  so  it  may 
be,  in  a  great  measure,  prevented  by  scrupulous  cleanliness, 
attention  to  drains,  free  ventilation,  and  plenty  of  cubic  space. 

In  a  case  where  it  has  declared  itself,  the  first  matter  which 
must  engage  the  surgeon's  attention  is,  therefore,  to  secure 
thorough  ventilation — in  fact  to  immerse  the  patient  in  a  fresh- 
air  bath.  The  medical  and  dietetic  treatment  should  be  stimulating 
and  supporting.  The  food  should  consist  of  beef-tea,  and  milk, 
with  a  little  wine  or  brandy.  If  there  are  superficial  abscesses, 
they  should  be  opened,  and  poulticed. 

Ammonia,  quinine,  bark,  and  the  chlorate  of  potash,  are  the 
remedies  that  hold  out  most  hope.     (F.  34,  42,  59,  65.) 

Indeed  the  treatment  of  pyajmia  may  almost  be  summed  up  in 
the  words — free  support  and  free  ventilation. 


91 


TBTAITUS 


is  a  disease  of  the  spinal  nervous  system — the  cord  and  the 
medulla  oblongata — and  indicates  an  undue  excitability.  It  may 
arise  spontaneously  {idiopathic),  but  much  more  often  it  follows 
an  injury  (traumatic). 

It  is  characterized  by  tonic  spasm  and  rigidity  of  the  muscles, 
with  frequent  exacerbations.  Sometimes  the  muscles  of  the  neck 
and  jaws  are  chiefly  or  solely  affected  {trismus).  Sometimes  the 
muscles  of  the  back  are  so  strongly  contracted  that  the  body  is 
bent  like  a  bow,  resting  on  the  head  and  the  heels  {opisthotonos). 

It  is  much  more  common  in  men  than  in  women,  and  usually 
occurs  during  the  early  years  of  adult  life. 

The  disease  may  be  either  chronic  or  acute.  The  chronic  cases 
are  generally  idiophatic,  and  often  recover.  The  acute  cases  are 
usually  traumatic,  and  are  very  fatal. 

Traumatic  tetanus  may  follow  a  mere  contusion,  but  much  more 
frequently  it  is  caused  by  a  wound.  Wounds  of  the  hands  and 
feet  are  particularly  apt  to  give  rise  to  it,  perhaps  because  these 
parts  are  highly  supplied  with  nerves.  Ragged  and  dirty  wounds 
are  more  dangerous  in  this  respect  than  those  which  are  made 
with  a  clean  sharp  instrument.  It  often  follows  burns.  The 
alternations  of  temperature,  heat  and  cold,  and  the  changes  in  the 
weather  seem  to  have  some  share  in  favouring  its  production. 

The  disease  may  come  on  when  the  wound  is  in  any  stage,  but 
most  frequently  it  shows  itself  during  the  period  of  cicatrization. 
The  symptoms  are  referrible  to  the  true  spinal  system,  and  indi- 
cate  extreme  irritability.  There  are  no  unusual  appearances  at  the 
seat  of  injury.  Indeed,  throughout  the  whole  illness  there  are  no 
local  phenomena  worthy  of  notice.  The  first  symptom  is  pain  and 
stiffness  about  the  neck.  This  soon  spreads  to  the  muscles  of 
mastication,  deglutition,  and  respiration.  Hence  the  popular  name 
of  the  malady — lock-jaw.  The  muscles  of  the  face  are  thrown 
into  strong  contractions,  giving  rise  to  a  characteristic  expression 
of  countenance — the  risus  sardonicus.  The  disease  next  extends 
to  the  diaphragm.  There  is  pain  at  the  ensiform  cartilage, 
shouting  backwards  and  causing  irregular  and  embarrassed  breath- 
ing. Gradually  the  muscles  of  the  abdomen,  back,  and  lower 
limbs  become  affected.  The  whole  body  is  stiff  and  rigid — perhaps 
strongly  arched,  resting  upon  the  occiput  and  the  heels.  The  arms 
and  the  tongue  are  among  the  last  parts  that  are  implicated. 

With  all  this  the  cerebrum  is  unaffected ;  the  mind  remains 
clear.  The  bowels  are  constipated,  and  the  stools  offensive. 
There  is  usually  but  little  fever.     It  is  true  the  pulse  is  quick 


92  TETANUS. 

and  the  skin  hot  and  perspiring,  but  this  may  be  explained  by  the 
strength  of  the  contractions,  and  the  pain  that  accompanies 
thera.  Sometimes,  however,  especially  as  the  disease  approaches 
a  fatal  termination,  very  high  temperatures  have  been  re- 
corded. 

Death  takes  place  either  from  apnoea  consequent  upon  spasm  of 
the  larynx,  or  from  exhaustion.  The  morbid  appearances  do  not 
throw  much  light  on  the  nature  of  the  disease.  There  is  gene- 
rally, but  not  always,  congestion  of  the  cord,  with  some  degree 
of  serous  effusion.  Dr.  Lockhart  Clarke  has  seen  softening  and 
disintegration  of  the  grey  matter.  Mr.  Erichsen  has  observed 
that  some  one  nerve,  leading  from  the  seat  of  inj  ury,  will  always 
be  found  distinctly  congested. 

Treatment. — When  there  is  a  suspicion  of  danger  the  wound 
should  be  excised ;  or  a  deep  incision  should  be  made  round  it  on 
its  proximal  side,  so  as  to  divide  its  nervous  connexions.  But 
when  once  the  disease  is  thoroughly  established  no  local  treat- 
ment seems  to  be  of  any  avail. 

The  constitutional  treatment  should  consist  in  the  administra- 
tion of  a  purgative — castor  oil  or  calomel,  for  example — and  this 
should  be  followed  by  enemata  from  day  to  day,  as  occasion 
requires.  To  moderate  or  suspend  the  muscular  contractions  the 
surgeon  may  try  the  effect  of  ice  to  the  spine,  or  the  inhalation 
of  chloroform,  or  full  doses  of  opium,  Indian  hemp,  Calabar  bean, 
chlorodyne,  or  chloral.  The  use  of  an  anaesthetic  will  at  least 
have  the  effect  of  mitigating  the  patient's  sufferings;  but  no 
remedy  has  been  found  which  appears  to  have  any  constant  or 
uniform  influence  over  the  disease.  Profuse  sweating  has  proved 
successful  in  Wagstaffe's  hands.  But  what  is  most  important  of 
all  is  that  the  patient  should  have  perfect  quiet — that  every 
possible  source  of  irritation  should  be  removed.  At  the  same 
time  he  must  have  plenty  of  beef-tea,  milk  and  other  fluid  food, 
with  brandy  or  wine,  to  support  his  strength,  and  to  resist  the 
tendency  to  death  by  exhaustion. 

Tetanus  sometimes  requires  to  be  distinguished  from  poisoning 
by  strychnia.  Speaking  generally,  the  symptoms  of  poisoning 
come  on  suddenly,  and  recur  in  paroxysms,  with  intervals  of  com- 
plete remission.  The  onset  of  tetanus  is  more  gradual,  but  when 
once  established  it  is  persistent,  though  subject  to  exacerba- 
tions. 

Hysteria  sometimes  simulates  tetanus;  but  the  imitation  is 
seldom  so  complete  as  to  give  rise  to  much  difficulty  in  the  diag- 
nosis. 


93 


HVSTERZa. 

is  a  disease  of  the  nervous  system,  characterized  by  more  or  less 
disturbance  of  volition,  sensation  and  emotion.  The  mind  has 
lost  its  firmness,  and  is  a  prey  to  morbid  fancies. 

It  is  a  disease  which  affects  women  much  more  often  than 
men.  It  generally  comes  under  the  notice  of  the  physician,  but 
it  is  necessary  that  the  surgeon  should  be  aware  of  its  manifesta- 
tions, or  it  may  betray  him  into  serious  errors  of  practice. 

In  an  "  hysterical  fit "  the  patient  becomes  insensible,  and  falls 
down.  She  lies  in  an  unconscious  state,  or  perhaps  talking  in- 
coherently, or  tossing  her  arms  about  in  a  restless  manner.  The 
pulse  and  the  temperature  are  not  afiected.  The  breathing  is 
slow  and  shallow ;  but  every  now  and  then  the  patient  relieves 
herself  by  a  long  sighing  inspiration.  Such  a  fit  may  last  for  a 
few  minutes  or  for  hours,  and  that  in  spite  of  all  that  can  be 
done  to  restore  the  patient. 

As  we  have  just  said,  hysteria  sometimes  simulates  tetanus,  at 
other  times  it  assumes  the  characters  of  spinal  disease,  or  of 
disease  of  the  joints  or  breast,  or  of  neuralgia,  or  of  other  com- 
plaints. Indeed,  there  is  hardly  a  malady  which  may  not  be 
modified,  if  not  altogether  simulated,  by  the  hysterical  tempera- 
ment. 

The  collateral  circumstances  of  the  case,  and  a  careful  examina- 
tion of  the  part  when  the  patient's  attention  is  directed  to  some- 
thing else,  will  generally  enable  us  to  form  a  correct  diagnosis, 
and  to  disentangle  the  real  from  the  imaginary  symptoms. 

Treatment. — When  a  patient  is  seized  with  an  "  hysterical  fit," 
cold  water  should  be  sprinkled  on  her  face  and  chest,  strong 
smelling  salts  applied  to  her  nose,  the  lips  moistened  with  brandy 
or  sal  volatile,  the  hands  and  feet  rubbed,  and  hot  water  bottles 
applied  to  the  body. 

When  the  "  fit "  is  over,  as  well  as  in  that  large  class 
of  cases  which  do  not  manifest  any  such  severe  symptoms,  we 
must  endeavour  to  improve  the  patient's  general  state  by  tonics 
(Fig.  47,  52, 66)  and  a  change  of  air,  as  well  as  to  brace  the  mind 
by  giving  it  healthy  occupation.  All  trifling  amusements  and  all 
listless  habits  should  be  forbidden,  and  the  patient  should  be  en- 
couraged to  follow  some  branch  of  industry  or  learning,  to  devote 
herself  to  some  active  work  of  charity,  or  to  practise  diligently 
some  accomplishment  or  fine  art  for  which  she  may  have  a  taste, 
and  which,  by  engrossing  her  attention,  will  divert  her  thoughts 
from  herself.     If  the  occupation  is  one  which  necessarily  takes 


94  CONSTITUTIONAL  EFFECTS. 

the  patient  much  into  the  open  air,  such  as  botany,  geology,  or 
sketching  from  nature,  it  is  likely  to  be  all  the  more  beneficial. 
At  the  same  time  late  hours  should  be  prohibited,  the  patient 
should  rise  as  soon  as  she  awakes  in  the  morning,  and  take  a  cold 
or  tepid  sponge  bath.  In  short,  a  well-regulated  dietary — using 
the  word  in  the  fullest  sense  which  its  derivation  suggests,  and 
including  not  merely  the  food  taken,  but  the  hours  of  meals,  and 
the  exercise  and  stated  employments  of  the  day — is  essential  to 
the  recovery  of  the  patient. 

Having  secured  the  observance  of  these,  the  most  necessary 
conditions,  some  mild  local  treatment  may  be  used  to  satisfy  the 
invalid.  But  we  must  carefully  abstain  from  all  such  active 
measures  as  we  should  employ  if  the  case  was  one  of  organic 
disease.  There  is  no  use  in  trying  to  argue  the  patient  out  of 
her  morbid  fancies.  They  are  real  to  her,  and  must  be  treated 
as  such.  Any  attempt  to  prove  that  they  are  merely  the  result 
of  a  diseased  imagination  will  only  aggravate  the  symptoms  and 
make  her  cling  to  her  delusion  with  all  the  greater  tenacity.  As 
Archbishop  Whately  justly  observes — "When  a  person  has  a 
morbid  fancy  the  worst  course  is  to  attempt  to  argjje  or  reason 
him  out  of  it ;  this  only  makes  him  the  champion  to  defend  it 
against  all  opponents.  The  only  way  is  to  lead  the  mind  to  other 
topics,  and  to  insensibly  cause  it  to  be  forgotten.  That  which 
did  not  come  in  at  the  door  of  reason  will  not  come  out  of  it." 


PART   IV. 

DISEASES   AND  INJURIES  OF  VAUIOUS 
PARTS— TISSUES   AND  ORGANS. 


CUTAZTSOTTS    Vl^CERS. 

The  skin  is  liable  to  be  affected  by  ulcers  of  various  kinds. 
Their  commonest  situation  is  the  leg,  just  above  the  ankle.  The 
ulceration  is  the  result  of  a  local  and  circumscribed  inflammation. 
Such  inflammation  may  have  either  a  non-specific  or  a  specific 
origin,  but  in  either  case  the  ulcers  are  divided  according  to  their 
characters  into  (1),  healthy  (2),  weak  (3),  indolent  (4),  irritable 
(5),  inflamed  (6),  phagedsenic. 

1.  The  healthy  ulcer  is  nothing  more  than  a  sore  when  it  is 
granulating  normally.  The  granulations  are  small,  regular,  close - 
set,  of  a  deep  rose  colour,  and  highly  vascular.  The  pns,  which 
bathes  the  surface,  is  laudable.  The  edges  have  a  bluish  or 
bluish-white  tint,  and  the  margins  have  a  tendency  to  contract. 

The  treatment  of  such  an  ulcer  is  of  the  simplest  kind.  A 
studied  position,  together  with  water-dressing,  or  a  little  simple 
ointment,  is  all  that  is  needed. 

When  the  sore  is  large,  such  as  is  sometimes  left  after  an 
extensive  burn,  the  healing  process  may  be  expedited  by  skin- 
grafting,  in  the  manner  recommended  by  M.  Reverdin.  A 
minute  piece  of  healthy  skin  is  raised  with  a  forceps,  cut  off  with 
scissors,  laid  upon  the  granulating  surface,  and  secured  in  that 
position  by  a  pad  of  dry  lint  and  a  strip  of  plaster.  The 
transparent  isinglass  plaster  is  particularly  well  suited  for  the 
purpose.  As  many  such  grafts  may  be  made  as  the  size  of  the 
wound  requires,  but  they  should  on  no  account  be  tried  unless 
the  ulcer  is  in    a    perfectly  satisfactory  state.     The  graft  need 


96 


DISEASES  OF  TISSUES  AND  OEGANS. 


Skin-graft. 


not  extend  through  the    whole   thickness    of  the    skin.     It  is 
enough  if  rather  more  than  the  cuticle  is  taken.     Fig.  30  repre- 
-p.     OA  sents  such   a   graft  on    the 

twelfth  day.  The  original 
piece  of  skin  transplanted 
was  about  the  size  of  a 
canary  seed.  It  not  only 
grew  rapidly,  but  it  seemed 
to  stimulate  the  edges  of  the 
wound  so  that  they  rapidly 
approached  one  another,  and 
the  whole  was  soon  healed 
over. 

.  The  medical  treatment  of 
ulcers  must  not  be  over- 
looked. In  some  cases  opium 
is  of  great  value ;  in  others, 
arsenic ;  and  where  there  is  a  syphilitic  taint,  mercury  or  iodide 
of  potassium  should  be  prescribed. 

2.  The  weaTc  ulcer  is  a  degenerated  form  of  the  preceding. 
From  some  cause — constitutional  or  local — the  granulations  be- 
come pale,  irregular,  and  flabby,  and  the  discharge  thin  and  serous. 
The  treatment  consists  in  using  stimulating  applications — e.g., 
ung.  zinci,  or  ung.  hyd.  nit.  or  zinc  lotion  (F.  25),  or  nitric  acid 
lotion  (F,  13) ;  while  the  part  is  supported  by  strapping  or  a 
bandage,  and  we  try  to  improve  the  patient's  general  health. 

For    strapping    an    ulcer   of    the    leg    the    surgeon     should 
provide    himself    with  a  number  of  strips   of  adhesive  plaster, 
about  an  inch  broad  and   long  enough   to  go   once  and  a  half 
-p.     Qi  round  the  part.     The  patient 

should  be  directed  to  place 
his  heel  on  the  edge  of  a 
chair,  and  then  the  sur- 
geon should  apply  the  strips 
of  plaster  in  regular  order 
from  below  upwards,  laying 
the  centre  of  the  strip  on 
the  limb  opposite  the  ulcer, 
and  bringing  the  ends  round 
and  crossing  them  over  the 
dressings  in  the  way  repre- 
Strapping  an  ulcer.  sented    in    Fig.    31.       The 

strapping  should  extend  from  a  little  below  the  ulcer  to  a  little 
above  it,  and  each  strip  of  plaster  should  overlap  the  preceding 
one  to  a  slight  extent,  so  that  there  may  be  no  intervals  between 


CUTANEOUS  ULCERS. 


97 


them.  After  the  strapping  has  been  applied,  the  leg  should  be 
bandaged  from  the  toes  upwards,  to  give  it  firm  and  even  support, 
and  to  prevent  it  from  becoming  cedematous.  For  this  purpose 
flannel,  cotton  elastic,  or  India-rubber  bandages  are  the  best. 

The  indolent  ulcer  is  often  seen  in  old  persons.     Its  most  com- 
mon situation  is  the  leg  just  above  the  outer  or  inner  malleolus. 


Fig. 


32 


and  sometimes  it  attains 
an  enormous  size  (Fig. 
32).  The  raw  surface  is 
pale,  smooth,  callous,  and 
not  unlike  a  mucous 
membrane.  The  edges 
are  abrupt,  thickened, 
hard,  and  white.  The 
adjacent  tissues  are  in- 
durated by  solid  oedema. 

The  treatment  consists 
in  destroying  the  callous 
surface  by  a  blister  or 
by  caustics,  and  then 
stimulating  the  ulcer  by 
such  lotions  and  ointments 
as  have  been  named  above, 
while  we  depress  the 
edges  by  strapping  or 
bandaging,  and  at  the 
same  time  give  support 
to  the  venous  circulation.  Indolent  iilcer  of  the  leg. 

Indeed,  the  treatment  of  ulcers  by  careful  strapping — the 
method  recommended  by  Mr.  Baynton  nearly  eighty  years  ago — 
is  too  much  neglected  at  the  present  day.  When  it  can  be 
thoroughly  carried  out  it  is  the  most  satisfactory  way  of  dealing 
with  a  chronic  sore.  Sometimes,  in  obstinate  cases,  which  are 
not  dependent  upon  varicose  veins,  the  operation  recommended 
by  Mr.  Gay  may  be  undertaken.  It  consists  in  making  an  in- 
cision through  the  skin  down  each  side  of  the  ulcer,  about  half 
an  inch  from  its  margin,  so  as  to  divide  the  thickened  tissues,  and 
allow  the  edges  of  the  sore  to  approach  one  another.  The  incisions 
must  be  filled  with  lint  to  prevent  them  from  closing  too  soon. 

4.  The  irritable  nicer  is  shallow,  with  thin  edges.  The  surface 
presents  a  number  of  irregular  granulations  of  a  dark-red  colour 
and  highly  vascular.  It  is  accompanied  by  constant  pain,  is 
extremely  sensitive,  and  bleeds  on  the  slightest  touch.  It  pours 
forth  a  thin,  acrid  secretion,  mingled  with  fragments  of  a  greyish 
slough.      Usually  the   whole  surface  has  been  irritated  by  the 

u 


98  DISEASES   OF  TISSUES  AND  ORGANS. 

friction  of  the  patient's  clothes,  or  some  similar  cause.  According 
to  Mr.  Hilton,  a  spot  may  sometimes  be  found  where  the  extreme 
sensibility  resides;  and  then  careful  examination  may  detect 
filaments  of  denuded  nerves.  In  such  a  case  an  incision  across 
the  course  of  the  nerve  will  destroy  sensation  and  secure  physio- 
logical rest. 

The  treatment  consists  in  removing  everything  that  can  fret 
the  sensitive  surface,  and  then  touching  the  part  thoroughly  all 
over  with  nitrate  of  silver.  This  may  be  repeated  every  two  or 
three  days.  During  the  intervals  the  sore  should  be  dressed 
with  sedative  or  anodyne  applications — e.g.,  nng.  plumbi  acetatls, 
or  lead  lotion  with  laudanum.     (P.  24.) 

Constitutional  treatment  is  here  of  the  utmost  importance.  The 
secretions  must  be  regulated,  the  health  improved  by  tonics,  and 
nervous  irritability  allayed  by  sedatives  or  narcotics  in  full  doses. 

5.  The  inflamed  ulcer  may  either  arise  from  an  aggravation 
of  the  original  inflammation,  or  it  may  be  induced  by  excessive 
stimulation. 

The  marcjins  are  red  and  swollen.  The  surface  is  soft  and 
friable,  emitting  a  profuse  and  unhealthy  discharge.  There  is 
heat  and  pain  in  the  part  with  constitutional  febrile  symptoms. 

The  treatment  should  be  mildly  antiphlogistic.  Aperients  and 
salines  should  be  given,  while  the  part  is  elevated,  and  constantly 
fomented  or  poulticed.  To  do  this  thoroughly,  the  patient  should 
lie  in  bed  with  his  leg  raised  on  a  pillow,  and  protected  from  the 
bedclothes  by  a  cradle.  Sometimes  leeches  may  be  requisite. 
When  the  inflammation  has  been  subdued,  water-dressing  is  all 
that  will  be  needed. 

6.  The  pJiacfedcBnic  ulcer,  when  it  is  not  syphilitic,  is  merely  an 
advanced  stage  of  the  foregoing.  The  ulceration  spreads  rapidly, 
the  tissues  breaking  down  and  becoming  disintegrated.  When 
sloughs  form  round  the  margins  of  the  wound,  and  the  tissues 
perish  en  masse,  the  disease  is  called  sloughing  pJiagedcena. 

These  varieties  of  ulceration  are  commonly  accompanied  by 
a  good  deal  of  pain  and  constitutional  disturbance.  They  indi- 
cate that  the  patient  is  in  bad  health  from  some  cause  which 
de])resses  the  system  and  vitiates  the  blood — the  exhalation  from 
drains,  for  example.  They  are  frequently  associated  with 
syphilis,  and,  when  this  is  the  case,  they  often  commence  in  the 
disintegration  of  a  subcutaneous  gumma. 

The  treatment  consists  in  placing  the  patient  in  favourable 
hygienic  conditions,  restoring  his  general  health,  destroying  the 
ulcerating  surface  by  escharotics, — the  strong  nitric  acid,  for 
examjjle — and  dressing  the  sore  with  antiseptic  or  stimulating 
lotions.     (l<\  12,  13,  25.) 


VARICOSE  ULCERS. 


HOSFITAI.  GAM-GRENZ:. 

It  sometimes  happens  that  sloughing  phagedaena  prevails  as  an 
epidemic  in  hospitals.  It  is  then  called  hospital  gangrene.  At 
the  present  day  this  disease  rarely  occurs  in  civil  practice.  It  is 
most  frequently  seen  in  naval  and  military  hospitals,  when  the 
wards  are  overcrowded  and  the  cases  severe,  and  when  it  is 
impossible  to  pay  proper  attention  to  cleanliness  and  ventilation. 
These  are  the  conditions  under  which  it  originates. 

When  once  established,  it  is  very  prone  to  spread,  the  poison 
being  conveyed  from  one  person  to  another  either  directly  by 
sponges,  dressings,  &c.,  or  indirectly  through  the  atmosphere. 

It  may  supervene  upon  a  wound  of  any  kind,  or  even  upon  a 
mere  bruise. 

The  edges  of  the  wound  become  painful,  swollen,  and  livid ;  a 
greyish  slough  covers  the  surface ;  the  discharge  becomes  thin 
and  scanty. 

If  the  disease  is  not  checked,  the  surrounding  tissues  soon 
become  gangrenous,  and  this  destructive  action  spreads  with  fear- 
ful rapidity.  Eones  may  be  exposed ;  or  vessels  may  be  opened, 
and  copious  hoemorrhage  may  ensue.  These  local  symptoms  are 
accompanied  by  great  constitutional  disturbance. 

Treatment. — The  patient  should,  if  possible,  be  placed  in  con- 
ditions more  favourable  to  health.  The  sloughing  surface  must 
be  destroyed  with  strong  nitric  acid  or  with  the  actual  cautery, 
and  the  resulting  wound  treated  on  general  principles,  with  a  free 
use  of  washes  containing  Condy's  fluid  or  carbolic  acid.  The 
strength  must  be  upheld  by  a  generous  diet  and  stimulants,  while 
pain  is  allayed  by  opium  or  similar  drugs.  It  is  hardly  necessary 
to  add  that  everything  should  be  done  to  prevent  contagion  and 
to  disinfect  the  atmosphere. 

VARICOSE    UXiCERS. 

A  great  many  ulcers  on  the  legs  are  due  to  the  presence  of 
varicose  veins.  All  such  ulcers,  whatever  other  characters  they 
may  have,  are  called  varicose  ulcers.     (See  Fig.  42.) 

The  special  treatment  must  have  reference  to  the  dilated  con- 
dition of  the  veins — while  the  limb  is  in  a  state  of  passive  con- 
gestion, from  the  retardation  of  the  venous  current,  it  is  almost 
impossible  to  cure  the  ulcer.  In  some  cases  the  varicose  veins  ad- 
mit of  being  obliterated.  In  other  cases  the  surgeon  must  be  con- 
tent to  support  them  by  means  of  a  bandage  or  an  elastic  stocking. 

As  the  surgeon  has  often  to  bandage  the  leg  not  only  for 
varicose  veins,  but  also  for  m.any  other  conditions,  we  shall  take 
this  opportunity  of  explaining  how  it  should  be  done.     Let  us 

H  2 


100 


DISEASES   OF  TISSUES  AND   OEaANS. 


suppose  that  the  right  leg  has  to  he  bandaged.      The  patient 
should    be     allowed    to     sit    in     an    easy    position    with    his 

heel     supported     upon     a 
Fig.  33.  chair  and   his  foot  placed 

in  the  mid-position  be- 
tween flexion  and  exten- 
sion. The  surgeon  then 
takes  the  bandage  in  his 
right  hand,  and  lays  the  ex- 
ternal surface  of  the  roU  on 
the  inner  ankle.  Then 
with  his  left  hand  he 
draws  out  a  few  inches  of 
the  end  of  the  bandage, 
and  this  free  extremity  he 
conducts  round  the  back  of 
the  ankle,  and  lays  it  across 
the  dorsum  of  the  foot. 
(Fig.  33.)  He  then  brings 
the  roUer  across  the  instep 
and  over  the  extremity  of  the  bandage.  In  this  way  he 
secures  the  end,  and  obtains  a  fixed  point  to  start  from.  He 
then  carries  the  roller  round  the  outside  of  the  foot,  keeping 
the  roll  of  bandage  close  to  the  skin,  and  makes  one  or 
two  circular  turns  round  the  foot,  a  little  above  the  roots  of  the 
toes.  The  bandage  is  next  brought  up  on  the  inside  of  the  arch, 
taken  over  the  dorsum,  then  round  the  ankle,  and  brought 
obliquely  across  the  instep  to  the  outer  edge  of  the  foot.  It  is 
now  carried  under  the  sole  as  before,  then  obliquely  across  the 
dorsum,  and  on  reaching  a  point  immediately  above  the  ankle  the 
bandage  is  conducted  in  simple  circular  turns  round  the  small  of  the 
leg  until  it  reaches  the  calf,  where  "  reverses"  will  be  required, 
in  order  to  make  it  lie  evenly.  (Fig.  34.)  The  "reverses" 
ought  not  to  be  placed  over  the  shin,  but  a  little  to  its  outer  side. 
When  the  bandage  has  reached  the  upper  part  of  the  calf,  it 
should  be  finished  ofi"  with  one  or  two  circular  turns,  and  fastened 
on  the  outside  of  the  leg. 

There  are  various  ways  of  commencing  this  bandage.  Some 
surgeons  begin  by  laying  the  end  of  the  roller  upon  the  instep  j 
others  upon  the  outer  edge  of  the  sole ;  but  all  agree  in  bringing 
up  the  bandage  on  the  inside  of  the  foot  so  as  to  support  the  arch- 
When  it  is  necessary  to  cover  the  heel,  the  surgeon  should  use 
an  "  arm-bandage,"  because  a  "  leg-bandage  "  is  rather  too  broad 
to  adapt  itself  readily  to  the  part;  and  a  flannel  roller  will 
generally  be  found  better  suited  to  the  purpose  than  a  calico  one. 


BOIL. 


101 


The  bandage  shoiild  be  applied  to  the  foot  in  the  ordinary  way, 
only  more  turns  will  be  required,  and  it  will  be  necessary  to  apply 


Fig.  34. 


them  more  closely  over 
the  heel.  It  is  always 
a  difficult  matter  to 
cover  the  heel  evenly, 
and  the  aid  of  a  few 
stitches  may  sometimes 
be  needed  to  enable  the 
surgeon  to  do  it  in  such 
a  manner  that  the 
bandage  shall  keep  its 
place  for  any  length  of 
time. 

But  to  return  to  the 
subject  of  varicose 
ulcers.  In  every  in- 
stance rest  in  the  hori- 
zontal position  with  the 

leg  raised  upon  a  pillow,  so  that  it  may  be  a  little  higher  than  the 
hip,  should  form  an  important  element  in  the  treatment.  The 
patient  should  be  warned  against  standing  much.  A  brisk  walk 
is  not  nearly  so  harmful  as  "  hanging  about  on  the  feet."  The 
general  treatment  of  the  sore  must  be  conducted  on  the 
principles  already  laid  down  and  accoi'ding  to  its  peculiar 
characters. 

Mr.  Hilton  recommends  that  those  who  have  varicose  ulcers 
should  raise  the  foot  of  the  bedstead,  on  which  they  habitually 
sleep,  a  few  inches  from  the  ground.  By  this  simple  device  an 
ulcer  which  has  once  been  healed  may  be  prevented  from  breaking 
out  again. 

BOII.. 

A  boil  ifurunculus)  is  a  limited  and  circumscribed  inflammation 
of  the  true  skin.  It  often  originates  in  a  sebaceous  follicle.  It 
is  attended  with  considerable  pain.  It  usually  runs  on  quickly 
to  suppuration,  bursts,  and  discharges  its  contents  by  a  single 
orifice.  Sometimes,  however,  it  advances  but  slowly.  There  is 
much  inflammation  and  induration  with  little  or  no  tendency  to 
suppuration.     This  is  what  is  popularly  called  a  blind  boil. 

Sometimes  the  boil  is  single,  but  more  frequently  a  number 
appear  at  once  or  in  succession. 

It  depends  upon  a  vitiated  state  of  the  blood,  from  living  too 
high,  or  living  too  low  ;  from  a  want  of  proper  exercise ;  or 
from  a  want  of  cleanliness.  Sometimes  it  is  excited  by  local 
irritation,  as  every  oarsman  knows.     Some  persons  are  subject  to 


102 


DISEASES  OF    TISSUES  AND  ORGANS. 


boils  every  spring,  depending  apparently  upon  the  feeble  state  of 
health  into  which  they  fall  at  that  season. 

Boils  generally  show  themselves  on  the  trunk,  more  particu- 
larly in  those  situations  where  the  skin  is  thickest,  as  the  shoulders 
and  buttocks. 

The  treatment  consists  in  clearing  out  the  bowels,  and  after- 
wards regulating  the  secretions.  The  diet  should  be  light, 
nutritious,  and  unirritating.  Tonics,  such  as  the  mineral  acids, 
quinine,  or  the  preparations  of  iron  or  of  arsenic,  should  be 
prescribed.  (F.  47,  52,  65.)  A  change  of  air  will  generally  be 
found  very  beneficial. 

Locally  the  boil  should  be  poulticed  or  treated  with  water- 
dressing  until  suppuration  takes  place.  If  it  is  slow  to  open,  it 
may  be  pricked  with  the  point  of  a  lancet,  and  the  poultice  con- 
tinued ;  but  if  it  breaks  naturally,  so  much  the  better. 

Blind  boils  should  be  touched  with  nitrate  of  silver,  strong 
nitric  acid,  potassa  fusa,  or  the  acid  nitrate  of  mercury,  and 
then  poulticed.  If  a  hard  indolent  swelling  remains,  it  shonld 
be  rubbed  with  a  stimulating  ointment,  or  painted  with  tincture 
of  iodine.  • 

CARBUXTCXiB 

(anthrax)  is  also  a  local  and  circumscribed   inflammation  of  the 
skin,  but  more  extensive  than  a  boil   and  more  severe  in  its 

symptoms. 

The  affected  part  becomes 
of  a  dull  red  colour,  slightly 
raised,  brawny,  and  intensely 
painful  and  tender.  In  two 
or  three  days,  it  suppurates, 
and  discharges  pus  from  a  num- 
ber of  points.  Large  portions 
of  the  skin,  and  of  the  sub- 
cutaneous cellular  tissue,  slough, 
and  a  foul,  irregular  sore  is  left. 
With  this  there  is  more  or 
less  constitutional  disturbance, 
generally  of  an  asthenic  kind. 

Carbuncle  occurs  most  fre- 
quently on  the  back  of  the 
neck,  the  shoulders,  and  but- 
tocks (Fig.  35).  It  is  dis- 
tinguished from  a  boil  by  its 
greater  size,  by  its  proneness 
to  spread,  by    the   flat  eleva- 


RUPTUEE  OF  MUSCLES   OR  TENDONS.  103 

tion  which  shows  no  tendency  to  "  point,"  and  by  the  number 
of  openings  from  which  the  discharge  escapes. 

It  is  a  disease  of  middle  and  old  age,  and  depends  upon  a 
faulty  condition  of  the  blood.  It  is  r\re  to  see  more  than  one 
carbuncle  present  in  the  same  individual.  The  prognosis  will 
depend  upon  the  size  and  situation  of  the  carbuncle,  upon  the 
age  and  constitution  of  the  patient,  but  most  of  all  upon  the 
soundness  of  the  viscera — especially  of  the  kidneys. 

Treatment. — An  aperient  should  be  prescribed  at  the  outset, 
and  followed  by  alteratives  and  tonics  as  occasion  requires. 
Opium,  or  drugs  of  the  same  kind,  will  have  to  be  given  in  full 
doses.  A  nutritious  diet  with  stimulants  will  be  needed  from 
the  first. 

The  local  treatment  consists  in  giving  a  free  vent  to  the  dis- 
charges and  sloughs.  This  may  be  done  by  nnaking  a  free  crucial 
incision,  or  several  small  straight  ones,  across  the  affected  pirt. 
This  should  be  done  early,  so  as  to  save  the  skin.  A  poultice 
should  then  be  applied  to  hasten  the  separation  of  sloughs.  Some 
surgeons  prefer  to  open  the  carbuncle  by  the  application  of 
potassa  c.  calce,  or  nitrate  of  silver.  The  potassa  fusa  answers 
admirably.  Two  or  three  pieces  the  size  of  a  pea  should  be  laid 
on  the  carbuncle,  and  secured  by  strips  of  plaster.  The  pain 
they  cause  is  trifling.  Sometimes  the  unhealthy  action  spreads, 
and  it  becomes  necessary  to  make  further  incisions,  or  to  apply 
caustics.  When  the  sloughs  have  all  come  away,  and  the  raw 
surface  has  assumed  a  healthy  character,  it  must  be  treated  on 
general  principles.  The  healing  process  is  usually  slow  and 
tedious. 

RUPTURE  OF  mUSCIiES  OR  TETiTDOWS. 

Muscles  or  tendons  are  sometimes  ruptured  by  sudden  and 
violent  action.  The  muscles  of  the  limbs  are  most  liable  to  this 
accident.  The  tendo  Achillis  is  particularly  apt  to  give  way. 
Sometimes,  however,  the  muscles  of  the  trunk  are  torn  across — 
e.g.,  in  tetanus. 

The  symptoms  are  sharp  pain,  sometimes  accompanied  by  a 
snapping  noise,  loss  of  power,  and  a  palpable  depression  in  the 
continuity  of  the  muscle  or  tendon. 

In  the  treatment  of  such  cases  the  great  object  is  to  relax  the 
muscle  or  tendon,  and  to  approximate  the  torn  surfaces.  The 
part  should  be  kept  at  perfect  rest  in  this  position  for  a  month, 
and  then  passive  motion  should  be  cautiously  made.  When  the 
tendo  Achillis  is  ruptured,  the  leg  should  be  flexed  at  the  knee, 
and  retained  in  that  position  by  a  cord  connected  at  one  end  with 
the  heel  of  the  patient's  slipper,  and  at  the  other  with  a  bandage 


104  DISEASES  OF  TISSUES    AND  ORGANS. 

passing  round  the  thigh.     For  some  time  after  he  begins  to  move 
about  he  should  wear  a  high-heeled  shoe. 

Repair  takes  place  by  the  effusion  of  plastic  material  within  the 
sheath,  and  this   material  gradually  becomes  organised   into   a  i 
structure  resembling  tendon.      But  it   will   probably    be    some ' 
months  before  the  patient  has  the  free  use  of  the  part. 

SFRAixrs. 

A  sprain  consists  in  the  sudden  and  forcible  stretching  of  the 
tendons  or  ligaments  connected  with  a  joint,  without  dislocation. 
Sometimes  the  tissues  are  more  or  less  lacerated.  The  accident 
is  accompanied  by  severe  pain,  and  followed  by  rapid  swelling.  It 
is  always  troublesome  and  tedious,  and  may  lead  to  serious 
results.  Many  a  case  of  joint-disease  has  originated  in  a  neglected 
sprain. 

The  treatment  should  aim  at  preventing  inflammation,  pro- 
moting absorption,  and  restoring  healthy  action.  During  the 
first  stage  the  part  should  be  kept  at  rest  in  an  elevated  position, 
and  cold  continuously  applied.  If,  notwithstanding,  there  is  in- 
flammation,  fomentations  should  be  used,  perhaps  even  leeches 
may  be  required. 

As  soon  as  the  acute  symptoms  have  subsided,  absorption 
should  be  promoted  by  systematic  rubbing,  with  or  without  stimu- 
lating liniments  or  ointments,  or  by  the  pressure  of  a  well-adjusted 
bandage.  If  the  patient  is  of  a  rheumatic  or  gouty  habit  of  body, 
the  bicarbonate  or  the  nitrate  of  potash,  with  colchicum  or  the 
iodide  of  potassium,  should  be  prescribed.     (F.  56,  61,  64.) 

Gradually  passive  motion  may  be  begun  in  order  to  restore  the 
part  to  its  proper  functions,  and  the  patient  may  be  allowed  to 
make  moderate  use  of  the  joint.  If  any  stiffness  remains,  warm 
salt  water  douches,  or  a  visit  to  the  thermal  springs  of  Bath,  Aix- 
la-Chapelle,  or  Bareges,  are  often  attended  with  benefit. 

Sprained  ankle. — Sprains  of  the  ankle  are  so  common,  and  so 
important,  that  their  treatment  deserves  a  special  mention. 

If  the  patient  is  seen  soon  after  the  accident,  nothing  more  is 
required  in  many  cases  than  to  support  the  part  by  applying  a 
roller  from  the  toes  to  a  short  distance  above  the  ankle,  or  by 
strapping  and  a  bandage. 

When  the  ankle  has  to  be  strapped,  the  surgeon  should  provide 
himself  with  a  number  of  strips  of  the  common  diachylon  plaster, 
about  an  inch  wide  and  long  enough  to  encircle  the  part.  These 
should  be  well  warmed  by  holding  them  before  the  fire,  or  by 
dipping  them  in  hot  water.  The  patient  should  then  be  directed 
to  place  his  foot  upon  the  edge  of  a  chair,  and  the  surgeon 
should  apply  the  first  strip  of  plaster  across  the  sole  of  the  foot, 


WHITLOW.  105 

immediately  above  the  roots  of  the  toes,  bringing  up  the  ends  on 
each  side,  and  crossing  them  on  the  instep.  Thus  he  applies  one 
strip   after  another,  each  strip  overlapping  Yig.  36. 

the  previous  one  by  about  a  third  of  its 
breadth,  until  the  whole  of  the  anterior  por- 
tion of  the  foot  has  been  covered.  The  next 
strip  he  passes  behind  the  leg,  applying  it 
immediately  above  the  heel,  and  bringing 
the  ends  forward,  one  on  each  side,  and 
crossing  them  in  front  of  the  ankle.  In 
this  way  he  places  as  many  strips  as  may 
be  necessary,  each  strip  rising  a  little 
higher  up  the  leg  than  its  predecessor. 
The  plaster  should  be  applied  firmly,  so 
as  to  make  a  slight  degree  of  pressure, 
and  if  the  strips  are  properly  placed  it  is  Strapping  the  ankle, 
only  the  point  of  the  heel  which  will  be  left  uncovered.  As  a 
rule  the  narrower  the  pieces  of  diachylon,  the  more  closely  will 
they  adapt  themselves  to  the  shape  of  the  part,  and  the  more 
even  will  be  the  support  which  they  afford.  If  the  plaster  does 
not  lie  flat,  or  if  its  edges  press  unduly  upon  the  skin,  and  impede 
the  circulation,  it  should  be  nicked  in  different  situations  with  a 
pair  of  scissors.  It  is  a  good  plan  to  apply  a  narrow  flannel  or 
calico  bandage  over  the  strapping,  so  as  to  fix  the  plaster  and 
give  additional  support  to  the  limb. 

If,  however,  the  sprain  is  not  seen  until  effusion  and  swelling 
have  taken  place,  then  it  may  be  necessary  to  confine  the  patient 
to  the  sofa,  to  enjoin  rest,  and  to  use  warm  or  cold  applications 
according  to  the  circumstances  of  the  case.  Sometimes  a  poultice 
or  a  fomentation  will  be  found  to  give  most  relief:  but  at  other 
times  the  surgeon  will  have  to  try  the  effect  of  a  spirituous  lotion 
or  a  bag  of  pounded  ice.  After  the  acute  symptoms  have  been 
subdued,  the  pressure  and  support  which  are  afforded  by  a  well- 
adjusted  bandage  will  be  found  of  great  benefit.  A  flannel  or 
cotton-elastic  roller  is  best  suited  to  such  cases ;  or  an  elastic 
gaiter  may  be  worn  with  great  comfort.  The  patient  should  be 
encouraged  to  use  his  ankle  in  moderation,  in  order  to  prevent  the 
formation  of  adhesions  about  the  joint. 

"WUITJmO'W. 

{Paronychia)  is  an  acute  inflammation  at  the  point  of  the  finger. 
It  may  be  considered  under  two  degrees.  The  first  and  most 
severe  form  is  that  which  affects  the  tendons  and  bone  ;  the 
second  involves  only  the  skin,  the  matrix  of  the  nail,  and  the 
subcutaneous  cellular  tissue. 


106  DISEASES   OF  TISSUES  AND    OEGAXS. 

1.  In  the  more  severe  variety  of  wlntlow  the  inflammation  is 
deeply  seated  from  its  commencement.  It  begins  in  the  sheath 
of  the  tendons,  or  in  the  periosteum.  The  redness  and  swelUng 
extend  to  the  hand  and  forearm.  The  tension  is  great.  The 
pain  is  intense  and  throbbing.  The  patient  gets  no  rest  by  night 
or  by  day,  and  is  worn  out  by  the  severity  of  his  malady. 
Matter  forms  in  the  course  of  a  few  days,  but  it  takes  a  long 
time  to  make  its  way  to  the  surface,  and  in  the  meanwhile  the 
vitality  of  the  bone  will  probably  be  impaired,  and  more  or  less 
of  it  destroyed. 

2.  The  milder  form  of  the  disease  generally  originates  in  the 
pulp  of  the  finger  or  in  the  matrix  of  the  nail.  The  patient,  who 
is  probably  out  of  health  at  the  time,  receives  a  prick,  or  a 
poisoned  punctured  wound,  near  the  end  of  the  finger.  The  part 
begins  to  swell,  and  becomes  hot,  red,  and  piinf'ul.  These  symp- 
toms increase  in  severity  until  matter  forms,  and  discharges 
itself.  Tlie  nail  will  probably  be  thrown  ofl',  and  its  place  gradually 
supplied  by  a  new  one. 

In  both  these  varieties  of  whitlow  there  is  more  or  less  con- 
stitutional disturbance,  according  to  the  severity  of  the  symptoms. 
The  bowels  are  constipated,  the  tongue  turred,  and  the  pulse  quick. 
At  the  same  time  the  blood  is  probably  in  an  impure  state, 
either  from  over-living  or  from  a  want  of  proper  nourishment. 

Treatment. — The  hand  should  be  supjiorted  by  a  sling  in  an 
elevated  position  so  that  the  fingers  point  towards  the  opposite 
shoulder.  The  bowels  should  be  freely  opened,  and  an  antiphlo- 
gistic regimen  adopted  as  long  as  the  acute  symptoms  last.  The 
part  should  be  constantly  poulticed  with  linseed  meal.  As  soon 
as  suppuration  has  taken  place,  a  free  incision  should  be  made ;  if 
possible,  at  the  side  of  the  finger,  so  as  not  to  impair  its  tactile 
power,  or  to  interfere  with  its  future  usefulness.  While  the 
inflammation  is  at  its  height,  sedatives  must  be  freely  given  to 
mitigate  pain  and  procure  sleep. 

If  the  bone  is  necrosed,  it  may  have  to  be  removed,  in  whole  or 
in  part,  before  the  sore  will  heal.  In  such  a  case  the  soft  tissues 
should  always  be  left,  and  supported  on  a  small  finger-splint. 
Even  if  the  entire  phalanx  has  come  away,  the  skin  and  nail  will 
make  a  very  useful  point  to  the  finger. 

When  the  thecal  inflai-nmation  has  been  extensive,  the  tendons 
are  apt  to  become  attached  to  their  sheaths,  and  the  utility  of  the 
finger  is  more  or  less  impaired.  Sometimes  it  is  left  stiff  and 
straight,  sometimes  it  is  contracted.  In  such  cases  soaking  the 
hand  in  warm  water,  rubbing  the  finger  with  soap  liniment,  and 
making  as  much  use  of  it  as  possible  will  be  likely  to  do  great 
good.     Forcible  flexion  and  extension  under  chloroform  may  some- 


GANGLION.  107 

times  be  practised  with  benefit.  As  a  last  resource,  when  the 
stiffness  cannot  be  cureil,  and  is  interfering  with  the  patient's 
livelihood,  amputation  may  be  performed. 

If  the  inflammation  spreads  to  the  hand  and  forearm,  as  it 
occasionally  does,  it  must  be  treated  on  general  principles. 

When  the  acute  symptoms  have  been  subdued,  a  course  of 
tonics  and  a  change  of  air  will  be  of  great  service  in  restoring 
the  patient's  health. 

GANGImION 
is  the  name  given  to  an  accumulation  of  fluid  upon,  or  within,  the 
sheath  of  a  tendon. 

Such  ganglia  are  of  two  kinds,  simple  and  compound. 

Simple  ganglia  are  encysted  tumours,  formed  in  the  fringes  of 
the  synovial  sheath.  Compound  ganglia  are  diffuse  collections  of 
fluid  in  the  sheath  of  the  tendon  itself. 

Each  variety  of  the  disease  appears  under  an  acute  and  a 
chronic  form.  Ganglion  is  often  caused  by  a  blow  or  a  strain, 
but  more  frequently  it  arises  spontaneously.  The  chronic  form 
of  compound  ganglion  is  sometimes  the  result  of  tenosynovitis. 

The  fluid  contained  in  a  ganglion  is  usually  straw-coloured  and 
viscid,  like  synovia.  Sometimes,  however,  it  is  brown  from  the 
admixture  of  blood.  Sometimes  it  contains  fibrinous  bodies,  like 
melon  seeds,  floating  in  it. 

The  tumour  presented  by  a  simple  ganglion  rarely  exceeds  the 
size  of  a  small  walnut.    (Fig.  37.)     It  is  smooth  and  rounded, 


Simple  ganglion  of  the  wrist. 

elastic  and  translucent.  It  grows  slowly  and  without  pain,  but 
as  it  increases  in  size  it  may  give  rise  to  a  good  deal  of  incon- 
venience by  interfering  witli  the  action  of  adjacent  parts.  It 
may  even  cause  acute  pain  and  sensitiveness  by  stretching  the 
nerves  that  pass  over  it.  This  is  peculiarly  apt  to  be  the  case 
with  those  about  the  palm  of  the  hand. 

The  simple  ganglion  generally  forms  in  connection  with  the 
extensor  tendons  of  the  wrist  or  ankle:  the  compound  is  often 
associated  with  the  flexor  tendons,  or  with  both  the  extensors  and 
flexors  at  the  same  time.     Fig.  38  represents  a  compound  ganglion 


108 


DISEASES    OF  TISSUES  AND  ORGANS. 


of  the  wrist.     The  patient,  a  young  woman,  was  a  laundress,  and 
the  disease  was  probably   brought  on  by  wringing  clothes,   and 

Fig.  38. 


Compound  ganglion  of  the  wrist. 

using  heavy  irons.  Both  wrists  were  sintiilarly  affected,  and  both 
the  flexor  and  extensor  tendons  were  involved. 

Treatment. — A  simple  ganglion  may  frequently  be  ruptured 
by  pressure  or  by  a  smart  blow,  and  then  the  contained  fluid  is 
absorbed.  Or  it  may  be  painted  with  tincture  of  iodine,  or 
smeared  with  a  mercurial  ointment,  or  with  an  ointment  com- 
posed of  equal  parts  of  ung.  hydrarg.  and  ung,  iodi,  or  blistered. 
While  any  of  these  measures  are  being  adopted,  it  should  be 
firmly  bandaged  so  as  to  promote  absorption,  and  fixed  upon  a 
splint,  so  that  it  may  have  perfect  rest. 

If  these  means  fail,  the  tumour  may  be  punctured  by  a  sub- 
cutaneous valvular  incision,  the  contents  let  out  into  the  sur- 
rounding tissues,  and  pressure  again  applied.  Or  the  tincture  of 
iodine  may  be  injected,  or  the  lining  membrane  scarified  so  as  to 
set  up  adhesive  inflammation.  Or  a  couple  of  silk  threads  may  be 
passed  through  it,  as  a  seton  ;  or  it  may  be  laid  open,  and  allowed 
to  heal  from  the  bottom ;  or,  as  a  last  resource,  the  cyst  may  be 
dissected  out.  These  operative  measures  are,  however,  attended  by 
some  risk.  When  any  of  them  are  undertaken,  the  part  should 
be  fixed  upon  a  splint,  so  that  it  may  be  kept  perfectly  at  rest. 

The  compound  ganglion  is  a  more  severe  affection,  and  will 
generally  be  found  very  obstinate.  It  must  be  treated  on  the 
same  principles  as  the  simple  variety.  The  effect  of  rest,  pressure, 
and  coimter-irritation  must  be  patiently  tried.  If  these  means 
fail,  a  seton  may  be  introduced,  or  tincture  of  iodine  injected,  or 
the  cavity  laid  freely  open.  But  operative  measures  must  not 
be  undertaken  without  great  caution.  If  diffuse  suppuration 
should  occur  in  the  sheath  of  the  tendon,  the  most  serious  con- 
sequences might  ensue. 

TEXrOSYHrOVXTIS. 

Sometimes  the  sheaths  of  tendons  become  acutely  inflamed 
[tenosynovitis).  Such  inflammation  is  generally  caused  by  sprains, 
or  by  the  violence  which  gives  rise  to  dislocations. 


INFLAMMATION   OF  BUES^. 


109 


In  addition  to  other  symptoms  of  inflammation — heat,  pain, 
tenderness,  loss  of  power — there  is  more  or  less  swelling  along 
the  course  of  the  tendon,  arising  from  effusion  into  the  sheath. 

When  the  surgeon  examines  the  part,  a  peculiar  creaking 
sensation  is  communicated  to  his  hand.  This  creaking  of  effusion 
has  sometimes  to  be  carefully  distinguished  from  the  crepitus  of 
broken  hone. 

Treatment. — The  local  treatment  of  acute  inflammation  of 
tendinous  sheaths  consists  in  rest,  fomentations,  leeches,  and 
blisters.  If  the  disease  becomes  chronic,  it  must  be  dealt  with 
as  a  compound  ganglion.  If,  as  often  happens,  there  is  reason  to 
believe  that  it  is  associated  with  a  rheumatic  habit,  appropriate 
medical  treatment  must  be  adopted.    (F.  56,  60,  67.) 

ZM-FIiAnxnCATIOM'  OF  BURS2:. 

Bursse  may  become  acutely  inflamed  from  external  violence, 
irritation,  or  undue  pressure.  Any  bursa  in  the  body  may  in  this 
way  give  rise  to  a  swelling ;  but  there  are  some  which  are  more 
apt  to  be  inflamed  than  others. 

Inflammation  of  the  bursa 
on  the  inner  side  of  the  meta- 
tarsal bone  of  the  great  toe 
gives  rise  to  a  bunion.  When 
the  bursa  between  the  tubero- 
sity of  the  ischium  and  the 
gluteal  muscles  is  afiected,  it  is 
popularly  called  "  weavers' 
bottom."  Enlargement  of  the 
bursa  under  the  deltoid  some- 
times needs  to  be  carefully 
distinguished  from  disease  of 
the  shoulder-joint.  The  bursa 
over  the  olecranon,  commonly 
calledtheminer'sorthestudent's  "  Student's  bursa,"  inflamed. 
bursa,  is  liable  to  be  inflamed.  In  the  case  from  which  Fig.  39 
was  drawn,  there  were  gouty  deposits  about  the  olecranon  which 
kept  up  constant  irritation.  The  bursa  connected  with  the 
semi-membranosus  may  give  rise  to  a  swelhng  in  the  popliteal 
space,  which  may  simulate  aneurysm.  The  bursa  between  the 
OS  calcis  and  the  tendo  Achillis  is  occasionally  enlarged,  causing 
a  swelling  at  the  back  of  the  ankle,  sometimes  on  one  side  of 
the  foot,  sometimes  on  both  sides.  Fig.  40.  But  the  bursa 
over  the  patella  is  that  which  is  most  often  afiected  in 
this  way,  constituting  what  is  known  as  housemaid's  knee 
(Fig.  41).     The  bursa  enlarges.     There  is  excessive  secretion,  and 


110 


DISEASES  OF  TISSUES  AND  ORaANS. 


Fiar.  40. 


Inflamed  bursa  behind  the  ankle. 


the  secreted  fluid  is  apt  to  become  purulent.  The  tumour  is  elastic, 
very  painful  and  tender  to  the  touch.     The  sliin  is  hot,  red,  and 

sometimes.  oedematous. 
With  this  there  is  gene- 
rally pyrexia — a  quick 
pulse,  a  white-coated 
tongue,  and  constipation. 
Treatment.  —  When 
the  inflammation  runs 
high,  the  patient  should 
have  a  light,  unstimu- 
lating  diet,  and  the 
bowels  should  be  kept 
freely  open.  The  part 
should  have  perfect  rest, 
the  limb  being  fixed  upon 
a  splint,  and  raised  on  a 
pillow.  Fomentations  or 
poultices  should  he  con- 
stantly applied,  and,  if  need  be,  leeches.  If  suppuration  takes  place, 
an  incision  should  be  made  at  once,  and  the  case  treated  as  an  acute 
Fig.  41.  abscess.    The  opening  should  be  over  the 

centre  of  the  patella,  and  the  direction  of 
the  incision  should  be  vertical.  Fig.  42 
was  drawn  from  a  patient  who  had  a  large 
suppurating  cavity,  a  bursal  abscess,  over 
the  patella.  When  she  applied  for  advice, 
it  had  already  broken  in  several  places. 
Though  it  had  a  formidable  appearance, 
it  was  easily  and  speedily  cured.  The 
patient  had  also  a  varicose  ulcer  on  the  \e^. 
If  the  inflammation  is  chronic — if 
there  is  an  indolent  swelling  which  gives 
inconvenience,  but  which  is  not  attended 
by  acute  symptoms — it  should  be  treated 
by  a  back-splint  and  the  pressure  of  a 
Housemaid's  Knee,  bandage.  At  the  same  time  it  should  be 
painted  with  iodine  tincture,  or  liniment;  or  covered  with  the  emp. 
ammoniaci  c.  hydrargyro,  or  with  lint  spread  with  ung.  hyd.  iodidi 
rubri;  or  it  may  be  blistered ;  or  a  seton  may  be  passed  through  it ; 
or,  if  the  tumour  is  so  solid  that  it  resists  all  milder  measures,  it 
must  be  excised. 

EXOSTOSIS 
signifies  an  outgrowth  from  bone.     It  is  met  with  under  two 
forms.     Sometimes  it  is  of  ivory  hardness,  composed  entirely  of 


EXOSTOSIS. 


Ill 


the  dense  tissue  of  bone  ;  sometimes  it  is  soft  and  spongy,  and  ba« 
the  structure  of  tlie  cancellated  tissue,  enclosed  in  a  sliell  of  hard 
bone,  and  overlaid  with  a  thin  cartilage. 

The  ioort/  exostosis  generally  springs  from  the  flat  bonea, 
particularly  those  of  the  head  and  face. 

The  cancellated  exostosis  is  usually  connected  witb  the  long 
bones.  It  is  most,  frequently  met  with  about  the  lower  end  of 
the  femur,  and  the  upper  end  of  the  tibia. 

Exostosis  is  a  disease  of  early  Fig.  42. 

adult  life.  Tumours  of  this 
description  are  often  multiple. 
Sometimes  they  seem  to  originate 
in  the  intiammation  caused  by 
external  violence ;  sometimes 
they  are  found  at  the  tendinous 
insertions  of  muscles;  sometimes 
they  result  from  the  bony  trans- 
formation of  a  fibrous  or  cartila- 
ginous tumour  connected  with  the 
periosteum;  frequently  they  arise 
without  any  assignable  cause. 

An  exostosis  grows  without 
pain,  though  it  soon  begins  to 
cause  inconvenience  by  the  pres- 
sure it  exerts  on  theneighbouring 
parts.  It  forms  a  smooth, 
globular  tumour,  hard  to  the 
touch  and  immovable.  Some- 
times it  is  attached  by  a  broad 
base ;  at  other  times  it  springs 
from  a  narrow  pedicle.  A  bursa 
is  often  developed  between  it  and 
the  tissues  which  lie  over  it. 

Treatment.  —  Constitutional 
remedies  are  not  likely  to  be  of  much  use  ;  still  the  iodide  of  potas- 
sium (F.  60)  or  the  corrosive  sublimate  (F.  50)  should  be  given,  iu 
the  hope  of  promoting  absorption,  or  at  least  of  arresting  growth. 

The  part  should,  as  far  as  possible,  have  perfect  rest.  If  the 
tumour  is  situated  on  one  of  the  limbs,  a  light  splint  should  be 
applied,  and  everything  should  be  done  to  allay  inflammatory 
action.  Not  unfrequently  exostoses  cease  to  grow,  and  remaiu 
stationary  for  years. 

If,  in  spite  of  our  efforts,  the  growth  goes  on  increasing,  and 
gives  rise  to  serious  inconvenience,  the  question  of  extirpatiou 
must  be  considered.     If  circumstances  permit,  an  incision  should 


Bursal  abscess  and  varicose 
ulcer. 


112  DISEASES   OF  TISSUES  AND  OEGANS. 

be  made  down  to  the  tumour,  and  it  should  be  removed  with 
Hey's  saw  or  with  bone-pliers ;  or  it  may  be  enucleated  in  the 
manner  described  by  Sir  James  Paget  (Med.  Chir.  Trans. ,yo\.  liv.). 
Sucb  an  operation  will  probably  be  followed  by  a  good  deal  of 
inflammation,  and  should  therefore  be  undertaken  with  caution. 
As  the  disease  is  purely  local  in  its  character,  it  is  not  likely  that 
it  will  reappear  after  it  has  been  once  thoroughly  removed. 

As  we  have  already  said,  bone  tissues  enter  more  or  less 
into  the  formation  of  various  other  tumours,  such  as  osteo- 
sarcomatous  growths  and  fibrous  and  enchondromatous  tumours. 

RICKETS 

(racMtis)  is  a  disease  of  the  bones  depending  upon  a  constitutional 
disorder  allied  to  scrofula. 

It  would  appear  that  the  animal  constituents  of  the  bones  are 
normally  deposited ;  but  there  is  a  deficiency  of  the  earthy  salts, 
and  at  the  same  time  an  expansion  of  the  cancellous  structure. 

Rickets  is  an  afiection  of  early  life,  and  generally  shows  itself 
about  the  period  when  children  begin  to  walk.  The  natural 
curves  of  the  bones  are  increased,  the  shafts  do  not  lengthen  as 
they  should,  and  the  articular  ends  become  enlarged.  These 
characteristics  are  most  apparent  in  those  bones  that  have  to  bear 
the  weight  of  the  body — the  lower  limbs,  the  pelvis,  and  the 
spine.  The  legs  are  short,  thick,  and  bent  forwards  and  out- 
wards. The  pelvis  becomes  compressed  and  deformed;  and, 
towards  the  approach  of  puberty,  the  spine  not  unfrequently 
shows  signs  of  lateral  curvature.  An  expansion  of  the  cranial 
bones  and  a  prominence  of  the  forehead  are  also  very  charac- 
teristic of  rickets.  In  process  of  time  the  shafts  of  the  long  bones 
become  strengthened  by  increased  deposit  of  osseous  matter  on 
their  concave  sides.  After  puberty  the  constitution  generally 
undergoes  a  change,  and  the  disease  makes  no  further  progress. 

Treatment. — As  the  disease  is  a  constitutional  one,  our  treat- 
ment must  be  directed  mainly  towards  improving  the  general 
health.  The  child  should  have  plenty  of  fresh  air  and  sunlight, 
good  and  sufficient  food,  warm  clothing,  and  regular  exercise.  He 
should  have  a  tepid,  cold,  or  sea-water  bath  every  morning,  and 
friction  should  be  applied  to  the  surface  of  the  body  to  promote 
the  action  of  the  skin,  and  the  development  of  the  muscles.  The 
secretions  should  be  carefully  regulated,  and  tonics  prescribed — 
especially  cod-liver  oil  and  the  preparations  of  iron.  Lime-water 
with  milk  sometimes  seems  to  have  a  beneficial  influence,  and 
Parrish's  **  Chemical  food"  is  an  excellent  remedy. 

As  long  as  the  disease  is  progressing,  the  child  must  not  be 
allowed   to  stand  or  walk   much — indeed,   the   less  the  better. 


MOLLITIES  OSSIUM.  113 

While  indoors  he  should  lie  on  a  couch,  or  on  a  mattress  spread 
u})on  the  floor,  or  he  encouraged  to  creep  "  upon  all  fours." 
When  in  the  open  air,  he  should  he  driven  in  a  carriage,  or 
wheeled  ahout  in  a  perambulator,  or  he  should  ride  a  donkey  or 
a  pony.  But,  as  far  as  possible,  the  recumbent  posture  should  be 
maintained,  and  that,  if  necessary,  for  a  year  or  two. 

If  the  spine  is  aflfected,  the  patient  should  lie  down  once  or 
twice  a  day  for  an  hour  or  two  upon  a  hard,  flat  sofa.  A  light 
mechanical  appliance  should  also  be  worn  so  as  to  take  the  weight 
ofi'the  vertebral  column,  and  to  press  upon  the  out-growing  part. 

In  the  same  way  if  the  legs  are  becoming  bent,  and  if  it  is 
impossible  to  take  the  child  entirely  ofi"  his  feet,  he  should  wear 
steel  supports,  which  will  have  the  advantage  of  enabling  him  to 
take  exercise  in  the  open  air,  while  they  prevent  the  deformity 
from  increasing. 

In  some  very  severe  cases  of  rickets,  Billroth  of  Vienna,  and 
Howard  Marsh  and  other  surgeons  in  this  country,  have  per- 
formed operations  with  the  view  of  straightening  the  legs.  Some- 
times the  bone  has  been  divided  subcutaneously;  sometimes  it  has 
been  laid  bare,  and  a  wedge-shaped  piece  excised.  These  opera- 
tions can  but  seldom  be  necessary,  and  they  should  never  be 
performed  till  the  acute  stages  of  the  disease  have  passed. 

XIXOXiIiITZES    OSSZUM 

{malacosteon,  osteomalacia)  is  another  disease  which  seems  to 
depend  upon  a  want  of  tlie  earthy  constituents  of  the  bones ; 
but  here  it  appears  that  there  is  degeneration  of  the  animal 
matter  as  well.  The  bones  become  soft  and  brittle,  and  are 
often  distorted  into  shapes  that  cause  the  patient  great  incon- 
venience and  distress.  Death  generally  takes  place  either  from 
exhaustion,  or  from  compression  of  the  lungs. 

MoUities  ossium  occurs  more  often  in  women  than  in  men,  and 
it  is  particularly  associated  with  the  child-bearing  period.  Unlike 
rickets,  it  is  a  disease  of  adult  life ;  and,  when  once  it  has  com- 
menced, it  gets  gradually  worse.  It  may  be  confined  to  a  few 
bones,  or  it  may  aflect  the  entire  skeleton.  The  urine  is  com- 
monly loaded  with  phosphates,  which  are  absorbed  from  the  bones 
and  excreted  by  the  kidneys. 

After  death  the  bones  are  found  to  be  light,  soft,  and  greasy. 
They  can  be  easily  broken,  or  cut  w  ith  a  scalpel.  The  cancellated 
tissue  is  often  expanded,  and  the  interspaces  filled  with  semifluid 
fat. 

All  that  we  can  do  in  the  treatment  of  this  disease  is  to  endea- 
vour to  improve  and  support  the  general  health.  Xo  remedy  has 
yet  been  found  which  has  any  specific  influence  over  the  malady. 

I 


114  DISEASES   OF  TISSUES  AND  ORGANS. 


PERIOSTITIS 

signifies  inflainmation  of  the  investing  membrane  of  bone.  It  is 
often  caused  by  exposure  to  cold,  or  by  external  violence ;  but 
still  more  frequently  by  an  impure  state  of  the  blood  arising  from 
syphilis,  scrofula,  or  rheumatism. 

The  subjacent  layer  of  bone  partakes  in  some  degree  of  the 
inflammation.  There  is  more  or  less  osteitis.  And  similarly, 
when  the  bone  is  primarily  inflamed,  there  will  be  more  or  less 
periostitis. 

When  the  disease  is  acute,  the  periosteum  becomes  thickened 
by  the  active  congestion  and  the  inflammatory  effusion.  There 
is  intense  pain,  and  exquisite  tenderness.  The  part  swells  and 
the  skin  around  becomes  red  and  oedematous.  In  the  course  of 
two  or  three  days  suppuration  takes  place,  and  then  the  mem- 
brane becomes  detached  from  the  subjacent  bone. 

When  the  inflammation  is  chronic,  a  flat,  hard,  circumscribed 
tumour —  a  node — forms.  There  is  deposit  of  plastic  material  in 
the  periosteum  and  neighbouring  parts.  There  is  great  pain, 
which  is  worse  at  night.  Chronic  nodes  are  generally  of  syphilitic 
origin,  and  when  such  nodes  are  situated  on  the  flat  bones — the 
cranium  for  example — they  often  suppurate,  but  when  on  the 
long  bones,  the  formation  of  matter  is  comparatively  rare. 

Acute  periostitis  is  attended  by  severe  constitutional  disturb- 
ance. In  the  chronic  form  there  are  generally  syphilitic  or 
rheumatic  symptoms. 

The  local  treatment  of  acute  periostitis  consists  in  an  elevated 
position,  leeches,  and  fomentations. 

When  suppuration  takes  place,  an  early  and  free  incision  should 
be  made,  and  poultices  applied.  Under  any  circumstances  necro- 
sis and  exfoliation  will  most  probably  ensue,  and  after  a  time  an 
operation  may  have  to  be  undertaken  in  order  to  assist  Nature  to 
throw  off  the  dead  bone. 

The  constitutional  treatment  is  that  of  acute  abscess. 

The  chronic  form  of  node,  if  it  depends  upon  syphilis,  is  gene- 
rally reduced  by  iodide  of  potassium  or  mercurj'.  (F.  50,  60.) 
Locally,  iodine  tincture  or  blisters  are  of  great  service. 

OSTEITIS. 

Bone,  as  well  as  the  soft  tissues,  is  liable  to  inflammation,  and 
such  inflammation  may  be  either  acute  or  chronic. 

Acute  inflammation  of  bone  is  generally  more  or  less  diffuse. 
Its  favourite  seats  are  the  shafts  of  the  long  bones.     When  it 


OSTEITIS.  115 

extends  to  the  medullary  merabrane,  it  runs  rapidly  along  the 
whole  length  of  the  canal.  It  occurs  most  frequently  in  children 
of  a  scrofulous  constitution,  and  in  those  who  are  out  of  condition 
from  want  of  the  necessaries  of  life.  It  is  often  caused  by 
exposure  to  cold  and  damp. 

The  attack  is  ushered  in  by  rigors  and  a  high  degree  of  fever. 
There  is  severe  deep-seated  pain  in  the  limb,  rapid  swelling,  and 
oedema,  with  an  erysipelatous  blush  on  the  surface.  The  inflam- 
mation runs  on  quickly  to  suppuration,  and  matter  points  in 
various  situations.  Bryant  draws  attention  to  the  fi\ct,  that  when 
the  pus  proceeds  from  inflamed  bone,  it  is  mixed  with  a  large 
quantity  of  oil-globules ;  and  this  is  an  important  diagnostic 
mark. 

If  the  patient  recovers  from  the  immediate  violence  of  the 
attack,  there  is  always  more  or  less  necrosis  of  the  bone.  When 
the  inflammation  has  spread  along  the  medullary  membrane,  it  is 
probable  that  the  articular. ends  will  sufler  as  well  as  the  shaft. 

The  treatment  of  acute  cases  consists  in  opening  the  bowels 
freely,  and  then  endeavouring  to  moderate  the  febrile  symptoms 
by  salines,  while  Dover's  powder  and  other  sedatives  are  given 
to  allay  pain.  (F.  7,  10,  53.)  The  part  should  be  elevated, 
and  constantly  fomented.  Leeches  may  sometimes  be  employed 
with  advantage.  As  soon  as  matter  forms,  it  should  be  let  out 
by  direct  incision,  and  poultices  applied. 

When  the  inflammation  is  chronic,  the  bones  become  slowly 
thickened,  and  perhaps  elongated.  The  bone-tissue  becomes 
dense  and  compact,  like  ivory.  Iodide  of  potassium  internally, 
with  local  counter-irritation,  is  the  treatment  which  holds  out  the 
best  hope  of  relieving  this  obstinate  disease.  (F.  60.)  Erichsen 
recommends  in  addition  that  a  linear  incision  should  be  made 
down  to,  and  through,  the  affected  bone. 

Occasionally  a  circumscribed  suppuration  takes  place :  an 
abscess  is  formed  in  the  bone.  Such  abscesses  are  small ;  they 
contain  pus  mixed  with  the  debris  of  the  osseous  tissue.  Their 
most  common  situation  is  the  cancellous  structure  at  the  upper  or 
lower  end  of  the  tibia.  They  may  generally  be  traced  to  an  in- 
jury.  The  skin  is  not  altered  in  appearance,  but  the  part  swells 
somewhat,  and  becomes  thickened.  There  is  aching,  deep-seated, 
intermittent  pain,  which  is  always  worse  at  night,  and  which  is 
aggravated  on  pressure.  The  patient  can  lay  his  finger  on  the 
spot  which  gives  rise  to  all  his  distress,  and  to  that  spot  the 
symptoms  are  invariably  referred. 

The  treatment  of  such  aii  abscess  consists  in  exposing  the  bone 
by  a  crucial  incision,  and  then  perforating  it  with  a  trephine,  so 
as  to  give  vent  to  the  pus,  and  allow  the  cavity  to  heal. 

i2 


116  DISEASES   OF  TISSUES  AND  OEGANS. 


CARIES 

is  commonly  described  as  the  molecular  death  and  disintegration 
of  bone. 

It  would  appear  that  the  nutrition  of  the  bone  undergoes  a 
morbid  change.  The  bone-tissue  becomes  soft  and  vascular.  Pre- 
sently it  breaks  down,  ulcerates,  and  is  discharged  in  the  form  of 
pus,  mingled  with  minute  fragments  and  spicula  of  bone. 

Caries  is  very  apt  to  begin  in  the  deep  layers  of  bone,  in  the 
centre  of  the  cancellated  tissue — perhaps  because  the  circulation 
there  is  feeble.  This  description  of  caries  is  very  common  in 
persons  who  are  of  a  strumous  habit  of  body,  and  is  often  found 
to  co-exist  with  tubercular  deposits  in  the  viscera. 

Sometimes,  on  the  other  hand,  it  attacks  the  surface  of  flat 
bones.  Here  it  produces  an  extensive  sore,  but  never  penetrates 
to  any  great  depth.  To  this  kind  of  caries  the  term  ulceration 
of  hone  is  sometimes  applied.  It  is  often  seen  on  the  surface  of 
the  cranium,  as  a  consequence  of  syphilis  (see  Fig*  161). 

The  early  symptoms  of  caries  are  much  the  same  as  those  of 
abscess.  There  is  pain  and  tenderness,  redness  and  swelling. 
Presently  an  abscess  forms,  and  discharges  itself.  It  is  then 
found  that  the  pus  is  gritty  and  offensive.  If  a  probe  is  passed 
along  the  track  of  the  abscess,  it  comes  in  contact  with  the  sur- 
face of  the  bone,  which  is  stripped  of  its  periosteum,  and  feels 
rough  and  excavated. 

The  appearance  of  a  part  afiected  with  caries  is  very  character- 
istic. The  tissues  are  thickened ;  the  skin  glazed,  and  of  a  dusky 
red;  while  here  and  there  are  the  openings  of  sinuses,  which  dis- 
charge a  thin  unhealthy  pus,  and  are  commonly  surrounded  by 
coarse  granulations.  It  is  evident  at  a  glance  that  the  disease  is 
of  a  chronic  inflammatory  character,  and  is  due  to  some  permanent 
source  of  irritation. 

Treatment. — The  first  thing  is  to  ascertain  whether  the  disease 
depends  upon  a  strumous  habit,  a  syphilitic  taint,  or  any  other 
special  cause  of  debility.  If  it  does,  we  must  endeavour  to  meet 
this  condition  by  appropriate  remedies.  Many  cases  of  caries 
improve  with  the  improvement  in  the  general  health,  and  ulti- 
mately undergo  a  spontaneous  cure.  Everything  therefore  should 
be  done  which  can  contribute  to  this  desirable  end.  The  part 
should,  if  ]iossible,  be  kept  at  rest  by  a  moulded  splint  of  leather 
or  gutta-percha  (see  Figs.  55  and  57).  The  patient  should  have 
a  change  of  air ;  if  possible,  he  should  go  to  the  sea-coast.  He 
should  have  a  light  but  nutritious  diet,  and  take  regular  exercise 
in  the  open  air.     At  the  same  time  alteratives  should  be  pre- 


NECEOSIS. 


117 


scribed,  together  with  cod-liver  oil,  or  the  preparations  of  iron 
or  of  iodine,  as  the  case  may  require.  (P.  45,  47.)  Locally 
counter-irritation  by  means  of  iodine  tincture,  blisters,  or  stimu- 
lating liniments  should  be  used. 

If,  notwithstanding  these  means,  the  disease  still  continues  in  a 
chronic  and  intractable  form,  we  must  consider  whether  the  case 
admits  of  an  operation. 

Tlie  simplest  operation  consists  in  removing  the  affected  sur- 
face of  the  bone,  in  the  hope  of  arresting  the  unhealthy  action. 
This  may  be  done  by  enlarging  any  fistulous  tracks  which  may 
exist,  and  taking  away  the  cai'ious  portions  of  bone  by  means  of 
a  gouge  or  other  suitable  instrument.  The  diseased  bone  is  soft 
and  friable,  and  crumbles  easily  under  pressure,  while  the  healthy 
bone  is  firm,  and  offers  a  natural  amount  of  resistance.  Before 
an  operation  of  this  kind  is  undertaken,  Esmarch's  bandage  should, 
if  possible,  be  applied.  It  restrains  the  haemorrhage,  and  enables 
the  surgeon  to  judge  of  the  condition  of  the  bone. 

If  the  operation  is  followed  by  healthy  action,  the  wound  soon 
heals  by  granulation. 

In  some  cases  the  gouge  is  inadequate  to  the  occasion,  and 
excision  or  amputation  will  have  to  be  performed. 


ig-ECROSIS 


is  the  term  given  to  the  destruction  of  bone  in  mass.     When  por- 


Fig.  43. 


tions  of  the  bone-tissue  perish 
as  a  whole,  without  undergoing 
disintegration,  they  are  said  to 
necrose. 

Necrosis  affects  chiefly  the 
hard  structure  of  bone,  and 
the  shafts  of  the  long  bones 
more  often  than  their  articular 
extremities.  In  these  two 
points  it  is  contrasted  with 
caries.  Fig.  43  was  taken  from 
a  boy,  aged  14,  who  died  of 
acute  necrosis  of  the  humerus 
and  tibia.  The  dead  and  dis- 
placed shaft  of  the  humerus  is 
seen  to  be  surrounded  by  a 
quantity  of  new  bone  which  has 
been  irregularly  thrown  out. 

As   in    the   case    of   caries,     ^'^^^  necrosis  of  the  humerus, 
whatever  lowers  the  vital   powers, — exhausting  disease,  syphilis, 
scrofula,  &c. — predisposes  to  necrosis. 


118  DISEASES  OF  TISSUES  AND  ORGANS. 

It  is  generally  excited  by  injury,  and  hence  it  is  more  frequent 
in  certain  exposed  situations,  as  the  shin,  than  elsewhere.  It  is 
very  apt  to  follow  the  spontaneous  inflammation  of  bone,  or  acute 
periostitis.  Those  who  work  among  the  irritating  fumes  of 
phosphorus,  as  lucifer-match  makers,  are  particularly  prone  to 
necrosis  of  the  lower  jaw. 

When  a  shell  or  scale  of  bone  separates  from  the  surface,  it  is 
called  an  exfoliation ;  when  a  portion  of  the  deeper  tissue  perishes, 
it  is  termed  a  sequestrum. 

A  case  of  necrosis  may  be  divided  into  two  stages — 1.  That  of 
death  and  separation ;  2.  That  of  renovation  and  repair. 

1.  The  symptoms  which  attend  the  death  of  bone  are  those  of 
acute  local  inflammation — great  pain  and  tenderness,  swelling  and 
oedema,  and  suppuration.  By  the  severity  of  the  attack,  the 
vitality  of  the  bone-tissue  is  destroyed  ;  and  then,  in  its  turn,  the 
dead  piece  of  bone  acts  as  a  foreign  body,  and  keeps  up  the 
inflammatory  action,  whereby  it  is  separated  and  thrown  off. 
The  separation  of  a  piece  of  dead  bone  is  effected  much  in  the 
same  way  as  the  separation  of  a  slough  in  the  soft  parts.  A  line 
of  demarcation  is  formed  between  the  living  and  the  dead  tissue. 
Along  this  line  disintegration  and  absorption  are  carried  on,  until 
separation  is  complete. 

2.  As  soon  as  the  dead  bone  has  been  detached  from  the  living, 
and  even  before  this  has  taken  place,  the  process  of  repair  begins. 
Granulations  spring  up  from  the  healthy  surface,  pushing  before 
them  the  exfoliated  bone.  This  is  one  of  the  chief  means  that 
nature  adopts  for  ridding  herself  of  that  which  has  now  become  a 
foreign  body.  But  it  often  happens,  especially  when  the  seques- 
trum is  of  large  extent  and  irregular  in  its  outline,  that  the  new 
bone  grows  around  it  and  embraces  it  in  such  a  way  as  to  prevent 
its  separation.  Hence  it  is  that  the  time  required  for  Nature  to 
throw  off  dead  bone  varies  extremely.  Sometimes  two  or  tliree 
weeks  are  sufficient ;  while,  in  other  cases,  the  process  is  not  com- 
pleted at  the  end  of  months  or  years.  Solly  relates  a  case  of 
necrosis,  after  fractuie,  in  which  exfoliation  was  still  going  on  after 
the  lapse  of  thirty  years  {Surg.  Experiences,  p.  307). 

If  the  suppuration,  which  necessarily  takes  place,  is  very  pro- 
fuse, hectic  may  be  induced,  and  the  patient  may  die,  worn  out 
by  the  exhausting  discharge. 

From  what  source  is  the  new  bone  produced  ?  Partly  from  the 
sound  and  healthy  bone  which  is  left,  and  more  particularly  from  the 
epiphysal  extremities ;  partly  from  the  periosteum  and  medullary 
membrane ;  partly  from  the  granulations  which  spring  from  the 
surrounding  soft  tissues.  When  the  periosteum  is  left,  it  supplies 
the  principal  part  of  the  new  bone — this  has  been  demonstrated 


NECROSIS.  119 

by  Oilier  of  Lyons  and  others;  but  when  it  is  destroyed, 
repair  takes  place  by  granulation  from  the  other  adjacent 
tissues.  When  the  shaft  of  a  long  bone  perishes,  and  bridges  of 
new  bone  are  thrown  across  it,  the  apertures  or  interspaces  are 
called  cloaccB. 

Treatment. — The  first  thing  to  be  done  is  to  endeavour  to 
remove  the  predisposing  cause — be  it  scrofula,  syphilis, 
general  debility,  or  anything  else.  The  principles  upon  which 
this  is  to  be  done,  have  been  already  laid  down  in  speaking  of 
caries.  If  the  necrosis  has  been  caused  by  the  fumes  of  phos- 
phorus, the  patient  should  at  once  be  removed  from  their 
influence. 

The  next  point  is  to  support  Nature  in  her  efforts  to  throw  off 
the  dead  bone.  Everything  should  be  done  which  can  improve 
the  general  health,  limit  the  suppuration,  and  husband  the 
patient's  strength.  It  is  astonishing  how  gi-eat  an  amount  of 
destruction  will  sometimes  be  repaired  by  the  efforts  of  Nature 
alone.  We  occasionally  see  cases  where  the  foot  is  fixed,  puffy, 
and  cedematous,  and  the  tissues  of  the  leg  thickened,  glazed,  and 
riddled  with  sinuses,  restored  to  a  sound  and  healthy  condition 
by  very  little  more  than  perfect  rest  in  the  horizontal  position; 
the  leg  being  raised  on  a  pillow,  or  suspended  in  a  "  Salter's 
swing"  (see  Pig.  SO),  and  treated  with  poultices,  water -dressing, 
or  stimulating  lotions. 

Until  a  line  of  demarcation  has  formed,  it  is  impossible  to  say 
how  much  or  how  little  of  the  bone  has  lost  its  vitality.  The 
surgeon,  therefore,  should  not  interfere  until  nature  has  com- 
pleted the  work  of  separation.  When,  however,  the  sequestrum 
is  deeply  situated,  it  is  no  easy  matter  to  say  whether  it  is 
detached  or  not.  Under  these  circumstances,  a  tentative  opera* 
tion  may  be  undertaken  after  the  lapse  of  a  moderate  time. 

When  the  diseased  bone  can  be  scooped  out,  Mr.  Pollock 
recommends  that  the  wound  should  be  packed  with  cotton  wool 
saturated  with  sulphuric  acid. 

In  some  cases,  a  very  slight  force  sufiices  to  remove  large 
portions  of  dead  bone.  Little  or  no  injury  is  done  to  the  soft  parts, 
while  the  cure  is  greatly  hastened.  In  other  cases  sinuses  have 
to  be  opened,  bridges  of  new  bone  have  to  be  divided,  and  after 
all,  the  sequestrum  may  be  very  imperfectly  removed. 

When  the  necrosis  is  situated  in  the  extremities,  if  it  is  very 
extensive,  if  it  involves  a  large  joint,  if  it  is  attended  with 
much  disorganization  of  the  soft  tissues,  or  if  the  suppuration 
and  hectic  threaten  to  prove  fatal,  amputation  will  have  to  be 
considered.  In  some  of  these  cases  the  limb  may  be  saved  by  a 
resection. 


120  DISEASES   OF    TISSUES  AND  ORGANS. 


FRACTURES 

are  caused  either  by  external  violence  or  by  muscular  action. 

External  violence  may  be  either  direct  or  indirect.  When  a 
bone  is  broken  by  direct  violence,  the  fracture  takes  place  at  the 
seat  of  injury.  When  it  is  broken  by  indirect  violence,  the  frac- 
ture may  take  place  anywhere  between  the  seat  of  injury  and 
the  point  of  resistance — as  when  the  clavicle  is  broken  by  a  fall 
on  the  shoulder. 

The  bone  which  is  most  frequently  broken  by  muscular  action 
is  the  patella.  It  is  torn  across  by  the  strength  of  the  quadriceps 
extensor  muscle  at  the  moment  when  it  is  stretched  across  the 
condyles  of  the  femur. 

Various  circumstances  predispose  to  fracture.  The  situation 
and  shape  of  the  bone,  the  presence  in  it  of  organic  disease,  the  age, 
sex,  and  constitution  of  the  patient — these  are  all  points  which 
influence  the  liability  to  fracture.  Thus,  a  bone  which  is  pro- 
minent, and  which  serves  as  a  point  of  support,  such  as  the 
clavicle,  is  very  apt  to  be  broken.  The  elastic  bones  of  children 
are  less  liable  to  fractures  than  the  firm  bones  of  adults.  Men 
are  more  exposed  to  accidents  than  women.  Where  there  is 
organic  disease,  the  bones  sometimes  break  from  very  slight 
causes.  Such  fractures  are  called  spontaneous,  and  are  often  slow 
to  unite. 

In  children  and  young  persons  fractures  frequently  occur  at 
the  line  of  junction  between  the  epiphysis  and  the  shaft  of  a 
long  bone. 

Fractures  are  of  various  kinds.  Sometimes  they  are  simple — the 
bone  is  merely  broken  into  two  pieces.  Sometimes  they  are  com- 
minuted— the  bone  is  broken  into  several  pieces.  Sometimes  they 
are  impacted — the  fragments  are  driven  into  one  another.  Some- 
times they  are  compound — the  fracture  communicates  with  an 
open  flesh  wound.  Sometimes  they  are  complicated — the  bone 
is  not  merely  broken,  but  some  large  vessel  or  some  internal 
organ  is  injured  as  well. 

Again,  fractures  are  named  transverse,  longitudinal,  oblique, 
&c.,  according  to  the  direction  of  the  fissure. 

Again,  fractures  are  usually  complete.  Sometimes,  however, 
they  are  incomplete — that  is  to  say,  the  bone  is  partly  bent, 
and  partly  broken.  The  greensiicic  fracture,  which  is  occasionally 
met  with  in  children,  is  the  best  example  of  an  incomplete  or 
partial  fracture.  Fig.  44  is  taken  from  a  preparation  in  Charing 
Cross  Hospital  Museum,  and  represents  a  greenstick  fracture  of 


UNION    OF   FRACTURES.  121 

the  ulna  in  a  boy,  aged  14.     The  particulars  of  the  case  were 
related  by  Mr.  Canton  in  the  Lancet  of  January  8,  1859. 

The    special  indications  -p.     ^^ 

of  fracture  are  loss  of 
power,  alteration  in  shape, 
unnatural  mohility,  and 
crepitus,  or  grating.  With 
these  signs  there  is  more 

or  less  pain  and  swelling.  "^Qreenstick  fracture. 

When  all  these  symptoms 
are  present,  they  prove  that  a  fracture  has  taken  place  ;  but  the 
surgeon  must  not  expect  to  find  them  all  equally  well  marked  in 
every  case. 

As  the  distal  part  of  the  bone,  to  which    the  muscles  are 
attached,  has  lost  its  support,  the  patient  is  unable  to  move  it, 
-  'inless  it  be  indirectly.     There  is,  therefore,  more  or  less  loss  of 
poiver. 

The  alteration  in  shape  is  caused,  either  directly  by  the 
violence  of  the  blow  which  produced  the  fracture,  or  by  subse- 
quent muscular  action.  In  ascertaining  the  nature  and  extent  of 
the  displacement,  accurate  measurements  should  be  made,  first  on 
one  side,  and  then  on  the  other,  taking  as  landmarks  some  of  the 
bony  prominences — the  acromion,  the  crest  of  the  ilium,  the 
trochanter  major,  &c.  In  studying  the  position  of  a  fractured 
bone,  the  surgeon  should  bear  in  mind  the  attachments  of  the 
various  muscles,  and  the  efiect  which  would  naturally  be  produced 
by  their  contraction. 

Though  there  is  on  the  patient's  part,  as  we  have  just  seen,  loss 
of  power  to  move  the  limb,  yet,  if  the  surgeon  grasps  the  injured 
bone,  he  finds  that  there  is  unnatural  mobility/.  The  broken 
fragments  move  freely  upon  one  another. 

But  the  most  important  and  valuable  sign  of  fracture  is  crepitus 
— the  grating  which  is  produced  by  rubbing  the  broken  ends  of 
the  bones  together.  This  grating  may  be  both  felt  and  heard. 
When  present,  it  is  an  unmistakable  indication  of  fracture.  But 
a  long  bone  may  be  broken,  and  yet  there  may  be  no  crepitus, 
because  the  fragments  are  impacted.  When  the  short  or  flat 
bones  are  broken,  we  are  not  so  well  able  to  avail  ourselves  of  this 
aid  to  diagnosis.  As  we  have  already  said,  when  speaking  of  teno- 
synovitis, this  crepitus  of  broken  bone  needs  to  be  carefully  dis- 
tinguished from  the  creaking  or  crackling  of  efiusion. 

UN-XOIO'  OF  FRACTURES. 

When  the  fragments  of  a  broken  bone  are  kept  in  apposition, 
union  takes  place  by  the  deposition  of  new  bone  around  and 


122  DISEASES  OF  TISSUES  AND   ORGANS. 

between  them.  Such  new  bone  is  called  callus.  That  which  is 
formed  first,  and  which  is  generally  very  abundant,  is  termed 
provisional  callus.  While  that  which  remains  ultimately,  after 
a  good  deal  has  undergone  absorption,  is  termed  the  definitive 
callus. 

When  a  simple  fracture  occurs,  the  injury  itself  sets  up  inflam- 
mation in  the  surrounding  tissues,  and  this  inflammation  is  of  the 
adhesive  kind.  Plastic  lymph  is  poured  out,  forming  a  thick  and 
dense  sheath — a  sort  of  natural  splint — around  the  broken  frag- 
ments. Between  the  ends  of  the  bones  the  same  plastic  material 
is  efi"used,  and  the  medullary  canal  is  filled  up  and  obliterated  by 
it.  Gradually  the  eff'used  lymph  becomes  developed  into  bone. 
When  it  is  first  deposited,  it  has  a  finely  granular  appearance 
under  the  microscope ;  then  cells  and  vascular  canals  are  found  in 
it ;  and,  ultimately,  it  assumes  all  the  characters  of  true  bone. 
Sometimes  it  passes  through  the  stage  of  fibrous  tissue,  cartilage, 
or  fibro-cartilage.  Although  the  bone  is  firmly  united  by  the 
end  of  six  weeks  or  two  months,  it  is  not  reduced  to  its  normal 
shape  and  size  until  after  the  lapse  of  a  considerable  time.  The 
superfluous  callus  undergoes  gradual  absorption,  a  fibrous  perios- 
teum is  formed,  a  medullary  canal  is  established,  and  at  length 
the  bone  returns  almost  entirely  to  its  natural  state. 

The  amount  of  provisional  callus  seems  to  depend  upon  the 
mobility  of  the  fragments,  and  the  depth  of  the  soft  tissues  that 
cover  them ;  in  other  words,  upon  the  degree  of  irritation,  and 
the  extent  of  tissue,  which  is  apt  to  become  inflamed  by  it. 
When  the  broken  bones  are  kept  in  accurate  apposition,  and 
when  they  are  covered  by  little  more  than  their  own  periosteum, 
the  provisional  callus  is  small  in  quantity.  In  impacted  fractures 
there  is  but  little ;  in  cases  of  broken  ribs,  on  the  other  hand, 
there  is  usually  a  great  deal. 

Union  in  compound  fractures  takes  place  somewhat  differently. 
Here  the  inflammation  which  is  excited  by  the  injury  is  not  of  the 
adhesive,  but  of  the  suppurative,  kind.  Pus  is  poured  out. 
Granulations  spring  up  around  and  between  the  fragments,  and 
in  these  the  osseous  matter  is  deposited.  The  amount  of  new 
bone  will  be  in  proportion  to  the  extent  of  the  granulating 
surface.  At  the  same  time,  there  is  apt  to  be  much  constitutional 
disturbance,  with  a  proneness  to  erysipelas,  phlebitis,  or  pya3mia. 

TREATIVIEIiTT    OF    FRACTURES. 

Simple  fractures, — In  treating  simple  fractures,  we  have  to 
aim  at — (1),  reducing  the  fragments  to  their  proper  position ; 
and  (2),  keeping  them  in  such  position,  until  nature  has  effected 
their  union. 


TREATMENT  OF  FEACTUEES.        123 

1.  No  time  should  be  lost  in  reducing  the  fragments.  The 
muscles  soon  become  rigidly  contracted,  and  then  the  difficulties 
of  the  case  are  greatly  increased. 

Sometimes  there  is  so  little  displacement,  that  there  is  no  need 
of  reduction.  All  that  is  then  wanted  is  to  study  the  position  of 
the  limb,  and  to  relax  the  muscles.  But,  in  other  cases,  we  have 
to  employ  both  extension  and  counter-extension. 

Extension  is  made  by  drawing  upon  the  distal  fragment; 
counter-extension  by  drawing  upon  the  proximal  fragment.  In 
every  case  the  force  should  be  applied  slowly,  gradually,  and 
continuously — without  jerking  or  violence.  Chloroform  is  of 
gi-eat  value,  by  enabling  us  to  overcome  muscular  rigidity  and 
spasm. 

2.  When  the  fragments  have  been  reduced,  our  next  care  is  to 
keep  them  in  position.  Here  again  it  is  of  great  importance  to 
maintain  the  studied  position  of  the  limb,  so  that  no  displace- 
ment may  occur  from  muscular  contraction.  But  in  most  cases 
something  more  than  this  will  be  requisite.  Bandages,  splints, 
or  mechanical  appliances  will  have  to  be  used. 

Some  fractures — fracture  of  the  clavicle,  for  example — may  be 
treated  by  bandages  alone.  But  in  the  majority  of  fractures,  a 
splint  of  some  kind  will  be  necessary. 

Originally,  no  doubt,  splints  were  straight  pieces  of  wood — 
splits  or  splinters — and  wooden  splints  are  still  by  far  the  most 
commonly  used;  but  from  time  to  time  splints  of  various 
materials  and  forms  have  been  introduced,  so  that  now  the 
surgeon  can  make  his  choice  among  a  number  of  appliances,  and 
select  that  which  is  best  suited  to  his  purpose. 

Wooden  splints  are  clean,  light,  and  cheap,  and  hence  they  are 
particularly  suitable  for  our  purposes.  Moreover,  they  can  be 
obtained  everywhere.  A  village  carpenter  can  easily  make  all 
the  ordinary  splints ;  and  even  the  surgeon  himself,  if  he  is 
furnished  with  a  half-inch  board,  a  saw,  and  a  knife,  ought  to  be 
able  to  supply  the  patient  with  an  apparatus  which  will  answer 
the  purpose.  If  the  surgeon  is  an  ingenious  man,  he  will  seldom 
have  any  ditBculty  in  finding  materials  to  form  a  temporary  ap- 
pliance; a  little  reflection  will  soon  suggest  something  which 
will  accomplish  the  object  that  he  has  in  view.  For  example,  a 
bundle  of  straw,  a  folded  newspaper,  the  board  of  a  book,  and 
many  other  things  have  been  used  on  an  emergency. 

The  variety  of  wooden  sphnts  is  great,  because  they  may  be 
made  to  serve  nearly  all  the  purposes  for  which  such  appliances 
are  called  into  use.  Some  are  straight ;  others  are  bent  at  a 
right  angle.  Some  are  flat ;  others  are  concave,  or  cut  out  so  as 
to  fit  the  part  for  which  they  are  intended.     Some  are  made  of  a 


124 


DISEASES   OF  TISSUES  AND  ORGANS. 


Fig.  45. 


single  piece  of  wood,  others  are  furnished  with  hinges.  Indeed, 
their  variety  is  almost  endless ;  and  when  a  student  first  goes 
into  the  splint-room  of  his  hospital,  he  will  be  amazed  at  their 
number;  but  a  short  experience  will  soon  teach  him  the  use  of  each. 
One  of  the  most  useful  kinds  of  wooden  splint  is 
what  is  known  as  the  common  lined  splint,  and 
which  may  be  obtained  at  any  surgical  instru- 
ment maker's  (Fig.  45).  It  consists  of  a  thin 
board  fastened  upon  a  piece  of  leather  or  canvas, 
which  accurately  fits  the  size  of  the  splint.  The 
wood  is  then  cut  lengthwise  with  a  number  of 
parallel  incisions,  which  penetrate  nearly,  though 
not  quite,  to  the  leather  or  canvas,  so  as  to  leave  a 
series  of  narrow  strips  of  wood  held  closely 
together  by  the  material  upon  which  they  are 
secured.  A  slight  degree  of  force  suffices 
to  separate  the  pieces  of  wood  entirely  from  one  another,  so  that 
a  hinge  is  formed  between  each  pair,  and  thus  the  splint  is 
capable  of  being  made  concave  throughout  its  whole  length. 
Moreover,  these  splints  have  other  advantages.  They  can  be 
used  as  flat  splints  by  simply  turning  the  wooden  side  towards 
the  limb  ;  and  the  surgeon  will  find  that  by  keeping  a  few  com- 
mon lined  splints  at  hand,  he  is  furnished  with  materials  which 
he  can  easily  cut  down  with  a  penknife,  so  as  to  form  small 
splints  for  fingers,  &c. 

Another  variety  of  splints  which  is  in  constant  use  is  that 
which  is  made  of  metal — either  of  japanned  iron  or  of  tin.  These 
splints  have  special  advantages.  They  are  thin  and  do  not  take 
up  much  space;  they  can  be  made  of  any  shape;  they  can  be  fitted 
with  hinges  or  screws  more  efficiently  than  wooden  ones,  and 
they  can  be  kept  cleaner,  as  they  do  not  allow  the  discharges 
to  soak  into  them.  As  a  rule,  these  metal  splints  are  made  for 
special  cases,  and  for  particular  parts.  It  is  to  complicated  cases 
— cases  requiring  special  mechanism — that  they  are  the  most 
applicable.  Thus,  those  wliich  are  commonly  used  for  excisions 
of  the  elbow  and  knee  are  made  of  japanned  iron,  because  the 
peculiar  form  of  apparatus  which  is  needed  for  these  cases  can  be 
made  more  efficiently  in  that  material  than  in  wood.  Again,  as 
an  example  of  the  simplest  form  of  metal  splints,  we  may  mention 
those  which  are  generally  used  for  cases  of  club-foot  in  infants. 
They  consist  of  a  flat  piece  of  tin,  of  suitable  length  and  breadth, 
rounded  at  the  corners  and  perforated  with  a  series  of  small  holes 
near  the  edge,  to  which  a  pad  can  be  attached.  These  splints 
have  the  advantage  of  being  very  cheap,  and  clean,  and  light ;  at 
the  same  time  the  surgeon  can  bend  them  to  any  angle  that 


TREATMENT  OF  FRACTURES.  125 

the  circumstances  of  tbe  case  may  require,  so  that  they  may  be 
made  to  serve  all  tbe  purposes  of  a  more  complicated  and  expen- 
sive apparatus. 

As  a  general  rule,  splints  are  applied  next  the  skin.  They 
should  therefore  be  well  padded  with  tow  or  cotton-wool.  Those 
splints  which  are  closely  moulded  to  the  form  of  the  part,  such 
as  the  gutta-percha  or  leather  splints,  will  not  require  padding, 
except  under  peculiar  circumstances. 

The  splint  is  to  be  fixed  by  means  of  bandages  firmly  and  evenly 
applied,  but  not  so  tight  as  to  impede  the  circulation. 

Bandages  or  rollers,  as  they  are  sometimes  called,  are  of  several 
difierent  kinds.  Those  which  are  most  commonly  used  are  made 
of  unbleached  cotton  or  calico.  Others  are  composed  of  a  woven 
cotton  fabric,  and  pass  under  the  name  of  elastic-cotton  or  stocking 
bandages.  Others  are  made  of  flannel — a  thin,  open  flannel, 
which  is  known  as  "  Domett"  or  "  Welsh  flannel  gauze."  Some- 
times a  coarse  muslin  roller  is  required,  as  in  the  application  of  a 
plaster  of  Paris  bandage. 

These  difierent  kinds  of  bandages  have  each  their  special  advan- 
tages, and  are  preferred  in  certain  situations,  or  for  particular 
purposes. 

Bandages  are  classed  under  three  heads,  according  to  their 
length  and  breadth;  and  are  spoken  of  as  arm-landages,  leg- 
handages,  and  rib-iandages.  But  each  of  these  is  suitable  for 
other  purposes  besides  those  which  its  name  indicates. 

An  arm-bandage  should  be  about  two  inches  wide  by  eight 
yards  long,  a  leg-bandage  two  and  a  half  inches  wide  by  ten 
yards  long,  and  a  rib-bandage  five  inches  wide  by  twelve  yards 
long.     These  are  the  dimensions  in  which, 
they  are  usually  cut,   and  which  wiU  be  Fig.  46. 

found  most  generally  useful  in  practice ; 
but,  of  coarse,  they  may  be  made  broader 
or  narrower,  longer  or  shorter,  according 
to  the  purpose  for  which  they  are  in- 
tended, and  the  situation  to  which  they 
are  to  be  applied.  It  is  always  well  that 
they  should  be  cut  ofi"  as  soon  as  their 
object  has  been  attained ;  there  is  no  ad- 
vantage in  making  more  turns  than  are  j^^ning  a  bandage, 
necessary. 

All  bandages  should  be  rolled  into  a  firm,  even,  and  compact 
mass.  This  may  be  done  perfectly  well  with  the  hand ;  but 
sornetimes  a  simple  machine  is  used  for  the  purpose.  The  machine 
consists  of  a  small  wooden  box  without  a  lid,  traversed  from  side 
to  side  by  a  rolhng-pin,  which  is  moved  by  a  crank  attached  to  it. 


126 


DISEASES   OF  TISSUES    AND   OEGANS. 


The  whole  is  not  unlike  a  miniature  barrel  organ.  The  end  of 
the  bandage  is  introduced  through  a  slit  at  the  extremity  of  the 
box,  and  fastened  to  the  rolling-pin.  The  handle  is  then  turned 
until  the  whole  length  of  the  bandage  has  been  rolled ;  the  rolling- 
pin  is  then  withdrawn ;  and  the  bandage,  ready  for  use,  remains 
in  the  box.  This  machine  has  been  variously  modified ;  but  the 
form  we  have  described  is  perhaps  the  simplest  in  use. 

One  method  of  rolling 
^^"      •  bandages  with  the  hand  is 

represented  in  the  annexed 
woodcut  (Fig.  46),  but   it 
is   a   plan    which    is  only 
suitable    to    narrow    ban- 
dages.     Another  method, 
which  is  applicable  to  all 
bandages  alike,  is  shown  in 
Fig.  47.     But  this  requires 
the  assistance  of  a  second 
person  to  hold  the  bandage 
out  and  make  it  tight. 
When  a  bandage  is  rolled  from  one  end  only,  it  is  called  a 
single-headed  bandage  ;  but  when  it  is  rolled  from  both  ends  it  is 
spoken  of  as  a  double-headed  bandage  (Fig.  48). 

Fi^.  48. 


Single-  and  double-headed  bandages. 

For  all  ordinary  purposes,  both  in  private  and  in  hospital 
practice,  there  is  nothing  so  generally  useful  as  the  common 
calico  or  unbleached  cotton  bandage.  It  is  cheap,  it  is  strong, 
and  it  is  clean.  It  is  admirably  adapted  for  fixing  splints,  for 
retaining  dressings,  or  for  keeping  parts  at  rest.  It  ought  to  be 
of  a  sufficiently  good  quality  to  tear  with  a  clean  edge,  and  to  be 
firm  and  unyielding. 

Sonrietinies,  however,  we  desire  a  bandage  which  shall  contract 
a  little  upon  the  part  to  which  it  is  applied,  so  as  to  keep  up  a 
slight  degree  of  pressure  or  aff  )rd  a  little  support ;  and  then 
we  have  recourse  to  an  elastic-cotton  or  to  a  flannel  bandage, 
pjither  of  these  may  be  very  appropriately  applied  to  an  cedema- 
tous  limb,  to  support  varicose  veins,  or  to  promote  absorption  of 
tlie  thickening  and  effusion  that  are  frequently  left  after  fractures 
or  other  injuries.     A  flannel  bandage  has  some  special  advantages. 


TREATMENT  OF   FEACTUEES.  127 

It  is  capable  of  absorbing  moisture,  it  retains  warmth,  and  its 
surfaces  adhere  to  one  another,  so  that  it  keeps  its  place  better 
than  any  other  kind  of  roller. 

As  fiir  as  possible  the  bandage  ought  to  be  made  of  one  con- 
tinuous piece,  without  any  joinings  ;  and  the  selvages  ought  always 
to  be  torn  off.  In  a  word,  the  surfaces  and  edges  of  the  bandage 
should  be  as  smooth  and  even  as  they  can  be  made.  There 
should  be  nothing  which  can  press  unequally  upon  the  part,  or 
constrict  it,  or  irritate  it  in  any  way. 

In  applying  a  bandage  it  is  necessary  to  secure  the  end  of  the 
roller,  and  to  get  a  point  upon  which  we  can  make  traction. 
Thus  we  often  take  a  turn  round  the  thigh  or  arm  for  no  other 
reason  than  to  fix  the  commencement  of  the  bandage. 

If  possible,  the  seat  of  fracture  should  be  left  uncovered,  so 
that  it  may  be  observed  from  day  to  day,  and  locally  treated, 
without  undoing  the  bandages.  If  it  is  desirable,  a  second  bandage 
may  be  applied  over  the  seat  of  fracture,  and  this  may  be  removed 
without  interfering  with  the  splints. 

Every  fracture  is  attended  with  more  or  less  inflammation. 
Sometimes  this  runs  so  high  as  to  give  rise  to  abscess.  When 
this  happens,  the  bandages  must  be  undone,  the  matter  evacuated, 
and  the  case  treated  as  one  of  compound  fracture. 

If  blood  has  been  extravasated,  its  absorption  may  be  promoted 
by  a  spirituous  lotion  (F.  21).  An  incision  should  never  be  made 
for  the  purpose  of  letting  it  out. 

All  fractures  are  apt  to  be  followed  by  slight  oedema  from 
inflammatory  effusion  or  extravasation.  But  if  the  swelling  is  so 
great  that  the  pressure  of  the  splints  and  bandages  interferes 
seriously  with  the  circulation — if  the  extremities  become  cold 
and  blue — then  the  bandages  must  be  loosened  at  once,  and  every 
care  taken  to  prevent  gangrene. 

If  erysipelas,  traumatic  delirium,  tetanus,  &c.,  follow  fracture, 
they  must  be  promptly  treated;  but  without  interfering  with 
the  special  apparatus  more  than  is  necessary. 

The  use  of  waxed  bandages  in  the  treatment  of  fractures  is  as 
old  as  the  time  of  Hippocrates  (Syd.  Soc.  translation,  i.  21), 
but  of  late  years  such  applications  have  come  much  more  into 
vogue  than  formerly  ;  and  the  use  which  is  now  made  of  bandages 
stiffened  with  solutions  of  starch,  dextrine,  or  other  substances,  is 
one  of  the  many  improvements  which  have  taken  place  in  modern 
surgery.  Such  bandages  are  particularly  suitable  to  the  treat- 
ment of  fractures.  They  form  a  light,  firm,  closely-fitting 
appliance,  well  adapted  to  keep  the  ends  of  a  broken  bone  in 
position.  By  this  means  we  are  sometimes  enabled  to  allow  a 
patient  to  leave  his  bed  in  a  few  days  after  he  has  met  with  a 


128  DISEASES  OF  TISSUES  AND  OEGANS. 

fracture  of  the  leg,  or  even  of  the  thigh,  and  to  go  about  on 
crutches  during  the  time  that  union  is  taking  place. 

The  starch  bandage  is  made  in  the  following  manner  : — The 
starch  is  mixed  with  water  until  it  forms  a  thick  paste  ;  and  if  a 
little  spirit  is  added,  it  will  dry  more  quickly.  A  cotton  roller  is 
then  moistened  with  the  paste  ;  and  in  doing  this  it  will  be  found 
convenient  if  an  assistant  rolls  up  the  bandage  as  the  surgeon 
unrolls  it,  and  saturates  it  with  the  starch-paste.  The  surgeon 
should  keep  the  basin  of  paste  at  hand  while  he  is  applying  the 
bandage,  as  well  as  rollers,  lint,  paste-board,  and  everything  else 
that  he  may  require ;  for  when  its  application  is  once  begun,  it 
ought  to  be  completed  without  delay  and  without  interruption. 

Having  made  these  preparations,  the  surgeon  first  of  all  lays 
a  piece  of  broad  tape  along  the  whole  length  of  the  surface  to 
which  the  bandage  is  to  be  applied.  The  object  of  this  will  be 
explained  immediately.  He  then  takes  a  narrow  flannel  roller 
and  binds  it  upon  the  part,  in  the  usual  manner,  in  order  to  pro- 
tect the  skin.  If  he  is  dealing  with  the  leg,  it  may  be  well  to 
cover  the  heel,  so  as  to  prevent  the  starch,  whan  it  dries,  from 
injuring  the  skin ;  and,  as  this  is  a  difficult  matter,  a  few  stitches 
may  sometimes  be  required  to  keep  the  roller  in  its  place ;  for  it 
is  important  that  it  should  not  slip  when  the  starch  bandage  is 
applied  over  it.  The  flannel  roller  should  form  a  thick  and 
complete  protection  to  the  part;  and  any  hollows  which  may 
exist  should  be  filled  up  with  a  little  cotton-wool  or  other  soft 
material. 

The  bandage,  which  has  previously  been  moistened  with  starch- 
paste,  should  now  be  applied  in  the  same  way  as  an  ordinary 
roller.  The  whole  surface  ought  to  be  covered  with  at  least  two 
layers  of  bandage ;  and  if,  after  this  has  been  done,  there  are  any 
parts  which  appear  weak,  they  should  be  strengthened  by  short 
strips  of  bandage,  or  of  lint,  in  order  to  give  the  necessary 
support. 

iSome  surgeons  prefer  to  envelop  the  part  in  a  layer  of  cotton- 
wool, instead  of  in  a  flannel  roller. 

When  the  starch  bandage  is  applied  for  fracture,  it  is  a  good 
plan  to  lay  strips  of  pasteboard  along  the  sides  of  the  limb  over 
the  flannel  roller  or  cotton-wool,  so  as  to  fix  the  joints  above  and 
below  the  seat  of  injury. 

Sometimes,  instead  of  a  roller,  short  strips  of  bandage  moistened 
with  the  starch-paste  are  folded  round  the  part  in  regular  order. 
Sometimes  the  roller  is  applied  dry,  and  the  paste  rubbed  into 
it  by  an  assistant,  as  each  fold  is  laid  down.  This  is  a  neater  and 
cleaner  method  than  the  one  which  we  have  described  at  length, 
but  it  does  not  make  such  an  efficient  bandage. 


TEEATMENT  OF  FRACTUEES.  129 

Bandages  of  this  sort  may  be  made  of  various  other  substances 
besides  starch.  Of  these  we  may  mention  dextrine,  lohite  of  egg 
and  flour,  and  poivdered  gum,  or  precipitated  chalJc.  We  have 
spoken  of  starch  because  it  is  the  cheapest  of  all,  and  because  it  is 
to  be  found  in  every  household.  But  whatever  substance  we 
select  as  the  basis  of  our  paste,  the  principle  of  application  is  the 
same  in  all  cases.  Our  object  is  to  moisten  the  bandage  with  a 
solution  which  will  not  interfere  with  the  pliability  of  the  roller, 
but  which,  as  it  dries,  will  harden,  and  form  a  firm  covering  for 
the  affected  part. 

When  a  starch  bandage  has  been  applied,  eight  or  ten  hours, 
or  perhaps  even  a  longer  time,  will  have  to  elapse  before  it  becomes 
dry  and  hard.  During  the  time  that  it  is  drying,  it  may  be  conve- 
nient to  lay  paper  under  the  part,  in  order  to  protect  the  bed- 
sheets  ;    care  being  taken  that  the  limb  is  in  proper  position. 

When  the  bandage  has  become  thoroughly  dry,  it  will  generally 
be  found  to  be  rather  loose.  If  this  is  the  case  it  should  be  slit 
up  throughout  its  whole  length  with  a  strong  pair  of  scissors,  or 
with  an  instrument  sold  for  the  purpose,  under  the  name  of 
"  Seutin's  pliers."  It  is  with  a  view  to  facilitating  this  operation 
that  we  have  recommended  that  a  piece  of  tape  should  be  laid  next 
the  skin,  as  the  first  step  in  the  application  of  the  bandage.  By 
this  simple  expedient  we  are  enabled  to  raise  the  bandage,  and  to 
slit  it  up  with  less  pain  and  risk  to  the  patient  than  if  we  had  to 
push  the  point  of  the  scissors  between  it  and  the  skin.  After  the 
bandage  has  been  slit  up,  it  may  be  reapplied  by  the  addition  of 
a  common  cotton  roller  on  the  outside.  In  this  way  a  light  case 
is  formed  which  fits  the  limb  accurately,  but  which  can  be  easily 
removed,  so  as  to  observe  the  exact  condition  of  the  part. 

If  there  is  any  sore — for  example,  the  wound  of  a  compound 
fracture — a  sort  of  small  door  may  be  cut  in  the  starch  bandage, 
so  as  to  admit  of  the  wound  being  dressed  without  disturbing 
the  general  arrangement. 

Paraffo-stearine  handages  were  introduced  to  the  notice  of  the 
profession  by  the  late  Mr.  Startin.  They  consist  of  rollers  saturated 
with  a  waxy  composition,  which  readily  melts  sufliciently  to  admit 
of  its  application  to  the  part,  and  then  quickly  hardens. 

These  bandages  are  said  to  have  the  advantage  of  being  con- 
venient and  cleanly,  and  easy  of  application  ;  moreover,  they  adapt 
themselves  with  great  exactness  to  the  shape  of  the  part,  so  that 
they  would  seem  to  be  particularly  suitable  for  cases  in  which  the 
surgeon  wishes  to  give  even  and  continuous  support,  as  in  varicose 
veins  and  ulcers  of  the  leg. 

A  plaster  of  Paris  or  gypsum  (Gr.  yv^os,  chalk)  splint  is  made 
in  the  following:  manner : — 


130  DISEASES  OF  TISSUES    AND  ORGANS. 

The  surgeon  takes  a  coarse  muslin  roller,  and  into  the  meshes 
of  this  he  dusts  the  dry,  powdered  plaster  of  Paris.  A  stock  of 
bandages  prepared  in  this  way  may  be  kept  rolled  up  and  ready 
for  use.  "When  the  surgeon  is  about  to  apply  one  he  ought  to 
have  at  hand  a  bag  of  the  dry  plaster  and  a  basin  of  water.  He 
then  proceeds  to  cover  the  limb,  which  has  to  be  bandaged,  with 
a  flannel  roller,  or  to  envelope  it  in  a  layer  of  cotton-wool.  After 
this  he  takes  the  roller,  which  has  been  previously  prepared,  and 
soaks  it  in  water,  or  pours  Vv'ater  upon  the  ends  of  the  roll  until 
the  whole  is  moistened.  He  then  applies  it  as  he  would  an  or- 
dinary bandage.  As  each  fold  is  laid  down  it  naay  be  necessary 
to  sprinkle  it  with  water,  or  to  dust  it  with  the  dry  powdered 
plaster,  in  order  to  strengthen  the  application.  After  a  sufficient 
amount  of  bandage  has  been  applied  in  this  way  the  outside  ought 
to  be  smeared  with  a  thick  paste  made  by  mixing  some  of 
the  plaster  with  water.  This  external  layer  ought  to  be  as 
smooth  as  possible,  not  only  to  give  the  splint  a  finished  appear- 
ance, but  also  that  there  may  be  no  irregularities  which  might 
catch  upon  the  bedclothes,  or  upon  the  patient's  dress.  In  a  few 
minutes  the  plaster  of  Paris  "  sets,"  and  forms  a  firm,  hard 
splint.  Care  must  be  taken  to  keep  the  limb  in  its  proper  position 
until  this  has  taken  place. 

Some  surgeons  prefer  to  apply  this  splint  in  the  form  of  short 
strips  of  bandage,  moistened  with  the  plaster  of  Paris  paste, 
and  folded  round  the  part  until  a  sufficient  thickness  has  been 
attained. 

Plaster  of  Paris  has  some  disadvantages  as  compared  with  starch 
or  dextrine.  It  is  more  bulky,  heavier,  and  less  easy  to  cut;  so 
that  if  the  splint  is  found  to  fit  badly,  or  if  the  limb  shrinks  away 
from  it,  it  cannot  be  slit  up  and  readjusted  without  a  good  deal 
of  difficulty.  On  the  other  hand  it  has  peculiar  advantages.  It 
"sets"  quickly,  it  forms  a  hard  and  unyielding  case,  and  the 
patient  cannot  remove  it  himself,  as  he  can  the  starch  bandage, 
and  this  is  sometimes  a  point  of  importance,  especially  in  dealing 
with  children  or  unruly  patients. 

The  "  Bavarian  splint"  is  an  improvement  upon  the  plaster 
of  Paris  sphnt  which  has  just  been  described.  It  is  made  in  the 
following  manner: — Two  pieces  of  flannel  are  cut,  long  enough 
and  broad  enougli  to  envelope  the  whole  part  to  which  the  splint 
is  to  be  applied.  These  are  laid  one  on  the  top  of  the  other,  and 
stitched  down  the  middle  line.  The  limb  is  then  laid  upon  them 
in  the  direction  of  the  stitching,  and  the  uppermost  layers  are 
folded  over  the  part,  and  secured  by  long  pins.  Thus  the  limb  is 
encased  and  protected  by  flannel.  The  mixture  of  gypsum,  of  the 
consistence  of  thick  cream,  is  then  applied  over  the  part ;  the  other 


TREATMENT  OF  FEACTUEES.  131 

laj'er  of  flannel  is  folded  over  it,  the  superfluous  plaster  is  rapidly 
scraped  away,  and  in  a  few  minutes  the  whole  case  will  have  "  set." 
The  pins  may  then  be  removed  from  the  inner  layer,  and  the  two 
halves  folded  back,  like  wings,  the  stitching  serving  as  a  hinge. 
If  the  flannel  is  turned  over  the  edges,  the  splint  is  complete,  and 
may  be  reapplied  by  means  of  webbing  and  buckles,  or  a  bandage. 
Gutta-percha  splints  are  made  in  the  following  way  : — 
First  of  all  a  shape  must  be  taken  of  the  part  to  which  the 
splint  is  to  be  applied.  This  may  be  done  with  paper ;  or,  better 
still,  with  a  piece  of  damp  calico.  When  an  accurate  pattern  has 
been  obtained,  the  surgeon  cuts  a  piece  of  gutta-percha  of  the 
same  shape  and  dimensions.  This  he  dips  in  boiling  water,  taking 
care  that  the  dish  which  he  uses  is  of  sufficient  size  to  contain  the 
gutta-percha  without  folding  it  upon  itself.  For  large  splints  a 
flat  tin  bath  serves  the  purpose  admirably,  while  for  smaller  ones 
an  old  tea-tray  or  a  foot-pan  may  be  conveniently  used.  The 
gutta-percha  soon  softens  under  the  influence  of  heat ;  and  when 
it  has  become  quite  plastic  the  surgeon  takes  it  out  of  the  water, 
dries  it  quickly,  and  then  lays  it  upon  the  part  for  which  it  is  in- 
tended. In  order  to  prevent  the  heat  from  being  painful  to  the 
patient  the  calico  shape  may  be  placed  next  the  skin,  and  the  gutta- 
percha laid  upon  it.  The  gutta-pevcha  ought  then  to  be  rapidly 
moulded  on  the  part,  and  a  roller  applied  over  it.  By  this  means 
it  adapts  itself  closely  to  the  surface.  After  it  has  cooled  it  may 
be  removed ;  and  it  will  then  be  found  to  have  taken  the  required 
shape.  The  edges  should  now  be  pared,  and  the  corners  rounded 
off;  after  which  the  splint  should  be  lined  with  wash-leather,  the 
leather  being  turned  over  the  edges,  and  continued  for  a  shore 
distance  on  the  outside.  It  is  a  good  plan  to  punch  holes  of 
variable  sizes  in  the  splint,  so  as  to  alloiv  a  free  circulation  of 
air,  otherwise  it  is  apt  to  become  inconveniently  hot  and  irksome 
to  the  patient,  when  it  has  to  be  worn  for  any  length  of  time 
(see  Figs.  55  and  57). 

Splints  made  of  sole  leather,  or  of  what  is  sold  under  the  name 
of  "  Spark's  leather,"  or  of  millboard,  may  be  formed  in  the  same 
way  as  the  gutta-percha  ones  which  we  have  just  described. 

Complicated  fractures. — A  simple  fracture  maybe  complicated 
by  laceration  of  the  main  artery.  "When  this  occurs,  a  diffuse, 
semi-elastic  tumour  rapidly  forms.  At  the  same  time  the  pulsa- 
tion ceases  in  the  arteries  on  the  distal  side  of  the  swelling. 
What  is  to  be  done  in  such  a  case  ?  A  tourniquet  should  be 
at  once  applied  to  the  main  artery  in  the  upper  part  of  its  course. 
If  this  arrests  the  bleeding,  the  pressure  may  be  continued,  and 
the  absorption  of  the  extravasated  blood  promoted.  If,  however, 
this  fails,  and  if  the  case  is  becoming  urgent,  a  ligature  may  be 

K  2 


132  DISEASES  OF  TISSUES  AND   ORGANS. 

put  round  the  main  artery  above  the  seat  of  injury — provided 
always  that  the  circulation  has  been  restored  on  the  distal  side 
of  the  swelling.  Or  the  tumour  may  be  laid  open,  and  the  ends 
of  the  artery  tied ;  but  this  practice  is  of  very  doubtful  expediency. 
Or,  lastly,  amputation  may  be  performed. 

Sometimes  a  fracture  is  complicated  with  a  wound  which  does 
not  communicate  with  the  broken  ends  of  the  bone.  In  such  a 
case  the  treatment  must  be  modified,  and  the  surgeon  will  have 
to  arrange  his  appliances  in  such  a  way  that  the  wound  may  be 
dressed  without  disturbing  the  position  of  the  fragments. 

Compound  fractures. — The  wound  which  communicates  with 
the  fracture  may  be  the  result  of  direct  violence  at  the  time  of 
injury,  or  of  a  sharp  fragment  of  bone  having  been  subsequently 
driven  through  the  skin  by  muscular  action,  or  it  may  be  caused 
at  a  still  later  date  by  sloughing  of  the  soft  tissues. 

Compound  fractures  must  be  "  set "  in  much  the  same  way  as 
simple  ones,  only  more  solid  splints,  such  as  Mclntyre's,  or  the 
fracture  box,  will  often  be  found  necessary.  Here,  however,  it  is 
essential  that  the  seat  of  injury  should  be  left  uncovered  by 
bandages.  If  one  of  the  fragments  protrudes,  and  there  is 
difficulty  in  reducing  it,  a  piece  may  be  cut  off  with  Hey's  saw, 
or  with  bone-pliers. 

Everything  should  be  done  by  an  elevated  posture,  perfect  rest, 
the  continuous  application  of  cold,  or  of  an  antiseptic  dressing, 
to  anticipate  and  prevent  inflammation. 

VVhen  the  wound  is  but  small,  it  should  be  covered  with  a 
pledget  of  lint  soaked  in  collodion,  in  Friar's  balsam,  or  even  in 
the  exuding  blood.  Beneath  this  artificial  scab  the  opening  may 
heal,  and  the  bone  unite,  as  in  the  case  of  a  simple  fracture. 

If  suppuration  is  once  established,  we  must  be  contented  with 
union  by  granulation.  A  free  vent  must  be  given  to  the  pus,  and 
the  wound  treated  on  general  principles — either  by  strictly 
antiseptic  dressing,  as  recommended  by  Lister,  or  by  poultices, 
water-dressing,  astringent  or  stimulating  lotions,  &c.  The  amount 
of  suppuration,  and  the  time  that  the  bones  take  to  unite,  will 
depend  chiefly  upon  the  extent  of  the  wound,  the  quantity  of 
tissue  destroyed,  and  the  constitution  of  the  patient. 

In  all  the  more  severe  cases  of  compound  fracture  in  the  ex- 
tremities the  question  of  amputation  will  arise.  Such  amputa- 
tion may  be  eitlier  primary  or  secondary. 

Pnmary  amputation — amputation  within  twenty-four  hours — 
may  be  required  when  the  bone  is  much  splintered  and  commi- 
nuted, when  the  soft  tissues  are  extensively  disorganized,  when 
the  main  vessels  are  torn,  or  when  a  large  joint  is  freely  opened. 

These  are  gome  of  the  circumstances  which  the  surgeon  should 


UNUNITED  FRACTURES  AND  FALSE  JOINTS.    133 

take  into  account,  in  determining  whether  a  primary  amputation 
should  be  performed  or  not.  At  the  same  time  the  age,  constitu- 
tion, and  habits  of  the  patient  are  points  of  great  importance, 
and  must  not  be  overlooked  in  forming  an  opinion. 

Secondary  amputation — amputation  after  active  inflammation 
has  subsided — may  be  required  on  account  of  gangrene,  extensive 
necrosis,  non-union,  &c. 

Sometimes  when  a  broken  bone  is  not  treated  at  all,  or  has 
been  badly  treated,  and  deformity  results,  it  may  be  necessary  to 
break  it  afresh,  in  order  to  put  it  in  proper  position. 

UXUNZTZD  FRACTURES    AlffB   TAJtSJl  JOINTS. 

Bony  union  may  fail  to  take  place  from  a  want  of  perfect 
apposition  and  of  rest,  from  an  insufficient  supply  of  blood  to  the 
fragments,  from  excessive  suppuration  and  necrosis,  or  from 
defects  in  the  general  health  and  condition  of  the  patient.  In 
the  first  two  cases  a  fibrous  or  ligamentous  union  takes  place — 
a  false  joint  is  formed.  This  fibrous  union  is  generally  all  that 
we  can  obtain  in  intracapsular  fracture  of  the  neck  of  the 
femur  and  in  transverse  fracture  of  the  pateUa.  In  the  other  two 
cases,  it  not  unfrequently  happens  that  there  is  no  union  at  all. 
Either  no  callus  is  thrown  out,  or  else  it  is  wholly  absorbed 
without  becoming  ossified.  Non-union  is  most  common  in  the 
humerus  and  in  the  femur.  On  the  whole,  it  is  a  rare  mischance, 
and  in  many  cases  no  satisfactory  reason  can  be  assigned. 

Treatment. — If  the  non-union  depends  upon  constitutional 
causes  or  phthisis  or  scurvy,  we  must  do  what  we  can  to  improve 
the  general  health  of  the  patient,  at  the  same  time  that  we 
adopt  suitable  local  measures. 

If  it  depends  upon  an  insufficient  supply  of  blood,  there  is 
but  little  hope  of  a  remedy.  In  a  suitable  case,  some  of  the 
measures  which  will  be  mentioned  immediately  should  be  tried. 
Generally,  however,  we  must  be  contented  with  fibrous  union, 
and  endeavour  by  means  of  a  special  splint,  or  other  apparatus, 
to  mitigate  the  inconvenience  arising  from  the  broken  bone. 

If  it  depends  upon  a  want  of  proper  apposition  and  of  rest,  the 
first  and  mildest  measure  is  to  put  up  the  fracture  firmly  in  starch 
bandages,  and  to  keep  it  so  fixed  for  a  considerable  time.  If 
this  fails,  various  means  of  exciting  inflammation  may  be  tried. 
The  ends  of  the  bones  may  be  roughly  rubbed  together ;  or  a 
seton  may  be  passed  through  the  false  joint;  or  the  ligamentous 
union  may  be  subcutaneously  divided  with  a  knife  or  with  a  noose 
of  wire.  If  these  means  do  not  succeed,  the  surgeon  may  cut 
down  upon  the  false  joint,  saw  off  the  ends  of  the  bones,  and 
treat  the  case  as  one  of  compound  fracture.     If  need  be,  the  in- 


134  DISEASES   OF  TISSUES  AND   ORGANS. 

flammatory  action  may  be  increased  by  inserting  ivory  pegs  into 
the  ends  of  the  bones.  As  a  last  resource,  amputation  may  have 
to  be  performed. 

FRACTURES  OF  THE  SKUIil^ 

always  arise  from  external  violence.  They  may  be  either  simple 
or  compound. 

The  skull  may  be  fissured  at  the  seat  of  injury,  or  by  con- 
trecoup,  the  force  being  applied  at  one  part  of  the  skull,  and  pro- 
ducing its  effects  upon  a  distant  and  more  fragile  part.  In  either 
of  these  cases,  the  fissure  may  traverse  the  outer  table  alone,  or 
the  inner  table  alone,  or  both  together.  Or,  again,  the  skull  may 
be  punctured  by  a  sharp-pointed  instrument,  causing  a  starred 
fracture.  Or,  again,  it  may  be  broken  into  fragments  and  commi- 
nuted, with  or  without  depression. 

The  dangers  which  attend  these  injuries  are — 1,  concussion  ; 
2,  compression ;  3,  haemorrhage  within  the  cranium ;  4,  inflam- 
mation of  the  brain  or  its  membranes  (see  p.  206). 

When  union  takes  place  in  fracture  of  the  skull  it  is  by  defi- 
nitive callus.  There  being  but  a  thin  covering  of  soft  tissue,  and 
little  or  no  movement  of  the  fragments,  the  provisional  callus 
which  is  formed  is  very  small  in  quantity. 

Simple  fissures  vary  greatly  in  their  extent.  They  may  be  very 
short,  or  they  may  traverse  the  entire  circle  of  the  cranium. 

Symptoms. — ^There  is  always  more  or  less  concussion.  After  a 
time  there  may  be  signs  of  compression  from  internal  hsemorrhage ; 
and  this  may  be  followed  by  symptoms  of  inflammation  of  the 
membranes,  or  of  the  substance  of  the  brain. 

The  aim  of  treatment  is  to  remove  any  causes  of  compression, 
and  to  anticipate  and  prevent  inflammation.  As  soon  as  the  patient 
begins  to  rally  from  the  shock  of  the  injury,  his  head  should  be 
shaved,  and  ice  or  cold  lotions  continuously  applied  (F,  21,  23). 
His  bowels  should  be  freely  opened.  His  diet  should  be  of  the 
most  unstimulating  kind,  and  perfect  quietness  and  rest  should 
be  enforced.  Some  surgeons  recommend  that  blood  should  be 
freely  taken  from  the  arm.  But  this  is  rarely  necessary,  and 
should  not  be  thought  of  unless  the  patient  is  of  a  full  habit 
of  body. 

Fracture  of  the  base  of  the  skull  is  an  accident  of  frequent 
occurrence  and  most  serious  import.  The  danger  is  lest  the  brain 
should  be  lacerated,  or  one  of  the  large  arteries  or  venous  canals 
torn  across. 

The  special  signs  of  this  accident  are  bleeding  into  the  orbit,  or 
from  the  nose  or  ears,  and  the  discharge  of  serous  fluid  from  the 
ears  or  nose.     When  the  blood  shows  itself  at  the  orbit  or  nose, 


FRACTURES  OF  THE  SKULL.  135 

it  points  to  a  fracture  through  the  anterior  fossa  ;  when  it  flows 
ft-om  the  ears,  it  shows  that  the  fracture  is  situated  in  the  middle 
fossa,  and  probably  runs  through  the  petrous  portion  of  the  tem- 
poral bone. 

The  bleeding  may  be  superficial,  and,  if  so,  is  unimportant.  If, 
however,  it  comes  from  within  the  cranium,  it  is  a  very  alarming 
symptom. 

The  serous  fluid,  which  is  sometimes  discharged  from  the  ears 
or  nose,  seems  to  be  derived  from  the  cerebro-spinal  fluid.  Its 
escape  proves  a  rupture  of  the  arachnoid.  The  fluid  itself  consists 
chiefly  of  water  with  some  common  salt,  a  little  albumen,  and  a 
trace  of  sugar. 

There  is  very  little  to  be  done  in  the  way  of  treatment.  All 
that  we  can  do  is  to  try  to  prevent  inflammation  on  the  plan 
already  laid  down.  , 

Fracture  of  the  sJciiU  with  depression  may  occur  without  pro- 
ducing any  serious  consequences.  In  such  cases  the  outer  table 
alone  is  depressed;  the  inner  is  left  uninjured.  Generally,  how- 
ever, the  inner  table  is  more  broken  and  depressed  than  the  outer 
one.  This  is  particularly  apt  to  be  the  case  in  gunshot  and 
punctured  wounds  of  the  skull.  Sometimes,  in  children,  the 
whole  thickness  of  the  skull  is  depressed  without  any  ill 
effects. 

Depressed  fractures  may  be  either  simple  or  compound.  When 
simple,  the  depression  may  be  masked  by  extravasation  of  blood, 
and  thus  there  may  be  difficulty  in  establishing  the  diagnosis. 
When  compound,  the  depression  may  be  felt  with  the  finger. 

The  special  dangers,  in  cases  of  depressed  or  comminuted  frac- 
tures of  the  cranium,  are  compression  of  the  brain  and  inflam- 
mation of  its  membranes.  The  latter  is  far  more  likely  to  prove 
fatal  than  the  former.  The  dura  mater  is  easily  inflamed,  and 
the  inflammation  rapidly  extends  to  the  brain. 

Treatment. — If  there  is  a  simple  fracture  with  depression,  un- 
accompanied by  any  symptoms  of  compression,  the  patient  should 
be  carefully  watched,  but  no  operation  should  be  undertaken. 
Under  such  circumstances,  it  is  better  not  to  convert  the  simple 
fracture  into  a  compound  one.  If,  however,  symptoms  of  com- 
pression come  on,  a  crucial  incision  should  be  made  without  delay 
over  the  seat  of  injury,  in  order  that  any  fragments  of  bone  that 
are  loose  may  be  removed,  and  any  portions  that  are  depressed 
may  be  elevated. 

If  the  wound  is  compound,  it  should  be  explored  with  the 
finger,  and  the  fragments  taken  away,  or  the  depression  elevated, 
as  in  the  foregoing  case. 

The  depressed  bone  may  be  raised,  by  introducing  an  elevator 


136  DISEASES  OF  TISSUES  AND  OEGANS. 

underneath  it,  and  using  the  handle  as  a  lever.  Or  it  may  be 
removed  with  Hey's  saw,  or  with  bone-pliers.  Or,  lastly,  a 
circular  piece  may  be  cut  out  with  the  trephine. 

It  is  surprising  how  much  the  brain  may  be  injured  without  a 
fatal  result.  I  have  elsewhere  related  the  case  of  a  boy  who 
received  a  compound  comminuted  fracture  of  the  skull,  with 
laceration  of  the  brain  and  loss  of  brain  substance,  and  yet  re- 
covered, so  that  he  could  return  to  his  work  and  earn  the  same 
wages  as  other  boys  of  his  age  (Path.  Soc.  Trans.,  xxi.). 
Subsequently,  however,  he  became  imbecile ;  and  I  suspect  that 
some  such  result  happens  in  all  these  cases,  after  the  lapse  of  a 
longer  or  shorter  time. 

FRACTURES  OF  THE  BOITES  OF  THE  FACE. 

The  nasal  hones. — These  bones  are  not  unfrequently  broken 
by  direct  violence.  The  bridge  of  the  nose  is  depressed,  and  the 
whole  organ  looks  flat  and  broad.  Such  injuries  are  accompanied 
by  a  great  deal  of  swelling  and  ecchymosis ;  and  until  this  has 
been  subdued,  the  exact  state  of  the  bones  cannot  be  ascertained. 

Treatment. — The  depressed  bones  should  be  elevated  by  a 
director,  polypus-forceps,  or  other  suitable  instrument,  and  re- 
tained in  their  proper  position  by  a  small  roll  of  lint  introduced 
into  the  nostril,  while  strips  of  plaster  and  small  pads  are  placed 
outside. 

The  lower  jaw. — Fracture  of  this  bone  only  occurs  as  the 
result  of  direct  violence.  Frequently  it  is  due  to  gunshot  injury. 
It  may  be  simple,  compound,  or  comminuted.  It  may  take 
place  anywhere,  but  its  most  frequent  seat  is  at  the  base  of  the 
bone,  near  the  bicuspid  teeth. 

The  diagnosis  is  generally  easy.  The  mental  portion  is 
depressed,  while  the  ramus  is  drawn  upwards  or  inwards. 
Crepitus  is  distinct.  The  point  of  fracture  can  be  felt.  The 
gums  are  lacerated.    The  saliva  dribbles  from  the  half-open  mouth. 

Treatment. — Teeth  which  are  only  loosened  should  be  left,  and 
secured  in  their  places  by  silver  wire.  Teeth  or  fragments  of 
bone  that  are  wholly  detached  had  better  be  removed.  When  the 
fragments  have  been  restored  to  their  proper  places  and  the  teeth 
brought  into  line,  the  jaw  should  be  fixed  in  that  position  by  a 
pasteboard  or  gutta-percha  splint.  Such  a  splint  may  be  made 
in  the  following  manner  : — A  piece  of  pasteboard  or  gutta-percha 
about  eight  inches  long  by  four  broad  is  taken  and  split  up  the 
middle  irom  each  end  to  within  an  inch  of  the  centre.  The 
material  should  next  be  dipped  in  hot  water,  so  as  to  make  it 
soft  and  pliable,  and  the  lower  limbs  folded  upon  the  upper  in 


FRACTURES   OF  THE   RIBS.  137 

the  way  indicated  in  Fig.  49.     The  splint  should  then  be  applied 
to  the  chin,  and  carefully  moulded  to  the  jaw.     By  a  little  mani- 
pulation, and  by  paring  the  edges,  it  may 
be    made   to  adapt  itself    closely  to    the  Fig.  49. 

part,  and  to  give  it  equal  and  uniform 
support.  It  then  only  remains  to  pad  it, 
and  it  is  ready  for  use.  It  should  be  re- 
tained in  its  place  by  a  four-tailed  ban- 
dage for  the  chin,  which  is  made  in  much 
the  same  way  as  the  four-tailed  bandage 
for  the  head,  only  it  is  narrower.  The 
surgeon  takes  a  piece  of  calico  about  three 
inches  broad  and  a  yard,  or  a  yard  and  a  Splint  for  lower  jaw. 
half,  in  length.     In  the  middle  line  of  this 

he  cuts  a  slit  large  enough  to  receive  the  point  of  the  chin ;  and  it 
adds  greatly  to  the  comfort  of  the  patient  if  the  slit  is  made  about 
an  inch  from  one  side  of  the  bandage,  so  that,  when  it  is  applied, 
and  the  narrower  portion  is  placed  upwards,  it  may  not  rise  so  high 
as  to  cover  the  lower  lip  or  the  mouth.  The  bandage  is  then  torn 
down  from  each  end  to  within  a  couple  of  inches  of  the  slit  for 
the  chin,  so  as  to  make  four  tails.  When  it  is  applied,  the  point 
of  the  chin  is  placed  in  the  slit — the  narrower  sides  being  up- 
wards. The  two  upper  tails  are  then  carried  horizontally  back- 
wards, and  tied  at  the  nape  of  the  neck,  or  crossed  and  brought 
round  in  front ;  after  which  the  two  lower  ones  are  conducted 
upwards,  and  fastened  on  the  top  of  the  head.  It  is  a  good  plan 
in  applying  such  bandages  as  this  to  leave  the  ends  of  the  two 
knots  sufficiently  long  to  enable  the  surgeon  to  tie  them  together, 
so  as  to  prevent  them  from  slipping.  Or  the  bandage  may  be 
retained  in  its  place  by  means  of  a  few  circular  turns  made  with 
another  roller  round  the  forehead,  and  secured  with  pins.  This 
bandage  is  also  useful  for  retaining  poultices  or  dressings  upon 
the  chin. 

When  the  lower  j;iw  is  broken  it  is  no  easy  matter,  even  by 
the  aid  of  a  splint  and  a  bandage,  to  keep  the  fragments  in  line, 
and  it  is  very  probable  that  some  degree  of  irregularity  will  be 
left. 

FKACTURES   OF  THE  RIBS. 

The  ribs  are  liable  to  be  broken  by  blows  or  falls,  or  by  a 
crushing  weight  passing  over  the  chest  or  back.  It  not  unfre- 
quently  happens  that  several  ribs  are  broken  at  once. 

When  the  injury  results  from  direct  violence,  any  part  of  the 
bone  may  be  broken,  but  when  it  is  caused  by  compression,  the 
fractm'e  is  generally  situated  at  or  near  the  angle. 


138 


DISEASES  OF  TISSUES  AND  ORGANS. 


The  symptoms  are  sharp  local  pain,  which  is  aggravated  hy 
drawing  a  long  breath,  and  great  tenderness  on  pressure. 
Crepitus  may  sometimes  he  felt  or  heard,  and  a  depression 
detected  in  the  outline  of  the  bone.  No  attempt  should  be  made 
to  elevate  such  a  depression. 

The  chief  dangers  are  lest  the  pleura  and  lung  should  be 
wounded,  giving  rise  to  pleurisy,  pneumonia,  or  surgical  emphy- 
sema ;  or  lest  the  case  should  be  complicated  by  laceration  or 
rupture  of  the  liver,  spleen,  or  other  of  the  abdominal  viscera. 

Treatment. — When  the  injury  is  confined  to  one  side,  the 
broken  ribs  should  be  supported  with  broad  strips  of  adhesive 
plaster  passing  half  round  the  chest.  In  this  way  they  are  kept 
at  rest,  while  the  respiratory  movements  of  the  sound  side  are  not 
interfered  with.  But  when  ribs  on  both  sides  are  broken,  a  broad 
roller  should  be  applied  in  circular  turns  round  the  chest,  begin- 
ning from  below  and  gradually  ascending — each  fold  overlapping 
about  a  third  of  the  preceding  one.  The  bandage  should  be 
drawn  sufficiently  tigbt  to  give  a  firm  and  even  support  to  the 
whole  chest.  In  order  to  retain  it  in  its  place,  a  separate 
strip  of  calico  should  be  passed  round  the 
neck,  in  the  form  of  a  brace,  with  the  ends 
coming  down  in  front  as  low  as  the  bandage 
extends.  These  ends  ought  then  to  be 
pinned — or,  better  still,  stitched — to  the 
circular  turns,  and  the  circular  turns 
ought  to  be  stitched  to  one  another,  so  as 
to  make  the  whole  into  a  firm  bandage, 
wliich  will  keep  its  place  for  some  time 
(Fig.  50,  a).  In  hospital  practice  a  calico 
bandage  is  generally  used,  and  answers 
the  purpose  sufficiently  well ;  but  a  flannel 
one  is  better,  for  it  both  gives  more  sup- 
port, by  exercising  a  slight  degree  of 
compression,  and  it  also  retains  its  place 
for  a  longer  time  without  requiring  to  be 
re-applied. 

Instead  of  this  roller  for  the  chest  some 
surgeons  prefer  to  use  a  lacing  body- 
bandage  ;  others  a  single  broad  binder  of  flannel ;  while  others 
again  employ  a  simple  belt  of  adhesive  plaster  about  a  foot 
broad  and  long  enough  to  go  once  and  a  half  round  the 
chest.  The  latter  is  a  particularly  suitable  application  for  chil- 
dren. Whatever  appliance  is  used  it  should  be  kept  on  for  a 
fortnight  or  three  weeks  at  least. 


[a)  Rib- bandage. 


139 


FRACTURES  OF  THB  CIiAVICIiX:. 

The  clavicle  is  very  often  broken,  pirtly  on  account  of  its  ex- 
posed position,  and  partly  because  it  forms  one  of  the  bearing 
points  of  the  upper  extremity. 

The  fracture  generally  occurs  about  the  middle  of  the  bone,  but 
sometimes  it  is  near  the  acromial  end. 

When  the  seat  of  fracture  is  near  the  acromial  end,  the  signs 
are  not  well  marked,  but  when  it  is  about  the  middle,  there  is 
a  displacement  which  is  very  characteristic.  The  outer  frag- 
ment is  drawn  downwards  and  inwards.  This  is  owing  partly  to 
the  weight  of  the  arm,  and  partly  to  the  action  of  the  pectoralis 
minor  and  subclavius  muscles.  The  inner  fragment  is  drawn  up- 
wards by  the  action  of  the  sterno-mastoid. 

Treatment. — When  the  clavicle  is  broken  near  its  acromial 
end,  all  that  is  needed  is  to  support  the  elbow  and  fore-arm  in  a 
sling,  and  to  put  a  broad  strip  of  plaster  over  the  seat  of  injury. 
Sometimes  a  few  turns  of  a  figure-of-8  bandage,  or  a  "  compound 
axillary  bandage,"  may  be  added  with  advantage,  in  order  to  keep 
the  shoulder  at  rest. 

The  compound  axillary  handage  is  a  ready  and  efficient  means 
of  drawing  back  the  shoulders,  and  may  often  be  of  use,  especially 
in  cases  of  emergency. 

It  requires  two  common  hand- 
kerchiefs, folded  in  the  form  of 
cravats,  about  three  inches  broad. 
One  of  these  is  passed  round 
one  shoulder  and  firmly  knotted, 
so  as  to  form  a  loose  ring.  The 
other  is  then  thrown  round  the 
opposite  shoulder  and  tied  in  a 
single  knot.  One  tail  is  then 
looped  through  the  ring  formed  by 
the  first  cravat,  the  necessary 
amount  of  tension  is  exerted,  and 
the  two  tails  are  tightly  fas- 
tened together.  A  glance  at  the 
woodcut  will  show  how  the  ban- 
dage is  adjusted  (Fig.  51). 

When  the  fracture  is  situated, 
as  it  generally  is,  about  the 
middle  of  the  clavicle,  something  more  than  this  will  be  necessary. 
There  are  then  three  points  to  which  special  attention  ought  to 
be  paid: — the  shoulder  should  be  drawn  back  by  a  figure-of-8 


Fisr.  51. 


Compound  axillary  bandage. 


140 


DISEASES  OF  TISSUES  AND  ORGANS. 


bandage ;  the  point  of  the  shoulder  kept  out  by  a  pad  placed  in 
the  axilla  ;  and  the  elbow  and  fore-arm  well  supported  in  a  sling. 
It  is  not  always  needful  to  carry  out  the  first  of  these  indi- 
cations, for  it  frequently  happens  that  the  displacement  is  so 
slight  that  there  is  no  over- riding  of  the  fragments,  and  then 
there  is  no  occasion  to  draw  back  the  shoulders,  and  we  are  able 
to  dispense  altogether  with  the  figure-of-8  bandage. 

The  axillary  pad  should  be  somewhat  wedge-shaped,  the  thick 
end  being  placed  upwards.  It  ought  to  be  broad  enough  to  keep 
the  shoulder  out  to  its  full  extent,  and  long  enough,  from  before 
backwards,  to  project  a  little  both  before  and  behind  the  axilla. 
It  may  be  made  of  folds  of  lint,  or  of  a  cushion  stuffed  with  bran, 
cotton-wool,  tow,  or  horsehair.  On  an  emergency  a  towel  or  a 
stocking  may  be  rolled  so  as  to  serve  the  purpose  sufficiently  well. 
^.      ,  For  an  adult  the  pad  ought 

°'      '  to  be  from  two  to  two  and  a 

half  inches  thick,  and  five  or 
six  inches  from  before  back- 
wards. In  some  cases  it  may 
be  necessary,  in  order  to  keep 
it  in  its  place,  to  tie  it  over 
the  shoulder  with  tapes  or  a 
bandage  (Fig.  52). 

In  rare   instances    it   may 
suffice,   after   placing    a    pad 
in     the     axilla,     to    support 
the    arm    in    a    sling,  with- 
Fracture  of  the  clavicle  (1).  Q^t  the   application    of    any 

bandage ;  and  in  such  cases  the  sling  ought  to  be  so  adjusted  as 
to  make  pressure  upon  the  elbow,  drawing  it  inwards  across  the 
chest,  and  at  the  same  time  pushing  it  slightly  upwards.  In  this 
way  the  humerus  is  used  as  a  lever  to  raise  the  point  of  the 
shoulder,  and  to  keep  it  out.  But  in  the  great  majority  of  cases 
the  arm  will  not  be  kept  sufficiently  still  by  means  of  a  sling  only. 
To  obtain  greater  security  we  have  recourse  to  bandages.  These 
are  sometimes  applied  in  the  manner  recommended  by  Desault,  and 
the  arrangement  bears  his  name.  The  surgeon  takes  an  arm 
bandage,  and  makes  a  turn  or  two  round  the  chest  so  as  to 
fix  the  end.  He  then  passes  the  roller  round  the  arm  of  the 
affected  side  in  such  a  way  as  to  fasten  it  to  the  chest,  and  draw 
it  well  forward,  and  support  the  fore-arm.  When  this  has  been 
done  he  takes  a  second  bandage,  and  binds  it  in  ovals  round  the 
elbow,  across  the  chest,  and  over  the  opposite  shoulder;  and 
finishes  off  with  three  or  four  circular  t\irns  round  the  chest  to 
fix  the  whole,  and  keep  it  in  position. 


FEACTUEES  OF  THE  SCAPULA. 


141 


The  accompanying  illustration  (Fig.  53)  represents  a  simpler 
method.  Here  the  numerous  oval  turns  are  dispensed  with,  and 
their  place  is  supplied  by  a 


single  fold  with  a  hole  cut 
in  it  to  receive  the  elbow. 

A  yet  easier  method,  and 
one  which  is  particularly 
suited  to  hospital  practice,  is 
to  fasten  one  end  of  a  ban- 
dage round  the  wrist  of  the 
aflected  side  by  a  clove-hitch, 
and  then  to  bind  the  arm  to 
the  side,  and  to  support  the 
elbow.  Thus  one  continuous 
bandage,  and  a  pad,  suffices 
for  the  whole  appliance. 

When  the  bandage  is  ad- 
justed, it  ought  to  be  pinned, 
or  stitched,  here  and  there,  so 
as  to  keep  it  in  place,  for  it 


Fig.  53. 


Fracture  of  the  clavicle  (2). 


is  very  apt  to  shift,  and  it  is  desirable  that  it  should  not  be 
moved  oftener  than  is  absolutely  necessary. 

In  infants  and  young  children  a  fractured  clavicle  may  be  con- 
veniently put  up  with  two  or  three  strips  of  plaster,  each  about 
a  couple  of  inches  broad.  If  necessary,  the  shoulders  must  be 
drawn  back  by  a  figure-of-8  bandage,  a  pad  must  be  placed  in  the 
axilla,  and  then  a  strip  of  plaster  passed  round  the  arm,  so  as  to 
bring  it  well  forward,  and  lix  it  upon  the  chest — the  ends  of  the 
plaster  being  made  to  adhere  to  the  chest  and  back.  A  second 
strip  of  plaster  is  then  to  be  passed  round  the  fore-arm  to  support 
the  elbow,  and  brought  up  before  and  behind,  and  attached,  like 
the  other,  to  the  back  and  chest. 

By  attending  to  these  directions  it  will  generally  be  easy  to 
bring  the  fragments  of  the  broken  bone  into  apposition,  though  it 
often  requires  constant  attention  to  keep  them  in  their  proper 
place.  It  will  usually  be  necessary  to  continue  the  use  of  the 
appliances  for  five  or  six  weeks. 

FRACTURES    OF    THE    SCAPUIiA. 

The  body  of  the  scapula  may  be  broken  in  any  situation,  but  as 
this  accident  can  only  occur  as  theresult  of  great  and  direct  violence, 
it  is  usually  associated  with  severe  injuries  to  the  ribs  or  spine. 

In  some  very  rare  instances  the  neck  of  the  scapula  has  been 
broken.  This  accident  is  so  uncommon  that  some  surgeons 
have  doubted  whether  it  ever  occurs  at  all.     There  can,  however. 


]42  DISEASES  OF  TISSUES  AND  ORGANS. 

be  no  question  about  it.  If  other  evidence  were  wanting,  a  case 
which  has  been  recorded  by  Speuce  in  his  "  Surgery  "  (Pt.  ii. 
p.  434),  and  which  was  verified  by  post-mortem  examination,  puts 
the  matter  beyond  a  doubt. 

The  acromion  and  the  eoracoid  processes  are  occasionally  broken 
off — the  latter  very  rarely,  the  former  more  often.  When  the 
acromion  is  fractured,  the  arm  hangs  useless  by  the  side,  the  out- 
line of  the  shoulder  is  flattened,  the  head  of  the  humerus  is 
slightly  depressed,  and  an  irregularity  may  be  felt  in  the  bone  at 
the  seat  of  injury. 

The  treatment  consists  in  supporting  the  arm  in  a  sling  so  as 
to  bring  the  two  fragments  of  the  bone  into  line.  The  union  is 
sometimes  by  bone,  but  more  often  by  ligament. 

FRACTURES  OF   THE  HUIVIERVS 

may  be  considered  under  three  divisions — those  of  the  upper 
extremity,  those  of  the  shaft,  and  those  of  the  lower  extremity. 

It  may  be  mentioned,  once  for  all,  that  these  fractures,  when 
they  occur  in  the  neighbourhood  of  joints,  are  often  attended  with 
so  much  inflammation  that  it  is  necessary  to  keep  the  patient  in  bed 
for  a  week  or  ten  days,  and  to  use  fomentations  or  cold  lotions. 

As  a  general  rule,  the  lighter  and  cooler  the  method  of  fixing 
splints,  the  more  agreeable  will  it  be  to  the  feelings  of  the  patient. 
The  irritation  which  arises  when  the  part  is  covered,  and  there 
is  no  escape  for  the  perspiration,  is  almost  intolerable,  and  it  is  of 
great  importance  to  be  able  to  undo  the  apparatus  easily,  and  to 
wash  the  limb  with  soap  and  water. 

FRACTURES  OF  THE  UPPER  EXTREMITY  OF 
THE  HUZVIERUS. 

This  bone  is  occasionally,  though  very  rarely,  broken  at  the 
anatomical  neck — i.e.,  just  within  the  line  of  insertion  of  the 
capsule  (Fig.  54).  Such  a  fracture  is,  of  course,  intra-capsular. 
It  may  be  either  simple  or  impacted. 

Fig.  54  was  drawn  from  a  specimen  in  which  the  line  of  frac- 
ture ran  throughout  the  greater  part  of  its  course  along  the 
anatomical  neck. 

The  signs  of  this  injury  are  rather  obscure.  There  is  pain, 
swelling,  loss  of  power,  the  outline  of  the  upper  end  of  the  bone  is 
irregular,  and,  if  the  fracture  is  impacted,  there  is  a  slight  degree 
of  siiortening.    If  the  fracture  is  simple,  there  may  also  be  crepitus. 

Separation  of  the  greater  tuberosity. — It  sometimes  happens 
that  the  greater  tuberosity  is  broken  off,  either  by  direct  violence 
or  by  muscular  action.  In  such  a  case  the  shaft  and  head  of  the 
bone  are  drawn  upwards  and  inwards,  while  the  greater  tuberosity 


FRACTURES  OF  THE  HUMERUS. 


143 


Fig.  54. 


is  carried  upwards  and  outwards.  By  this  displacement  the 
breadth  of  the  shoulder  is  increased  to  a  remarkable  degrree,  and 
the  separation  of  the  frag;ments  is  very  distinct. 

Fracture  at  the  surgical  necJc — i.e.,  at  that  part  of  the  bone 
which  lies  between  the  tubercles  above,  and  the 
insertion  of  the  latissimus  dorsi    and  associated 
muscles  below. 

In  this  accident  the  upper  fragment  is  turned 
upwards  and  outwards  by  the  muscles  which  are 
inserted  into  the  greater  tuberosity,  while  the 
lower  fragment  is  drawn  upwards  and  inwards 
by  the  deltoid  and  the  pectoralis  major. 

Signs. — The  head  of  the  bone  is  in  its  right 
place,  but  below  it  there  is  a  depression.  The 
lower  fragment  points  beneath  the  skin  in  the 
direction  of  the  coracoid  process.  The  limb  is 
shortened,  and  crepitus  can  easily  be  obtained. 

In  children  the  fracture  not  unfrequently  hap- 
pens at  the  line  of  junction  between  the  epiphysis 
and  the  shaft  of  the  bone.  It  is,  in  fact,  a  sepa- 
ration of  the  upper  epiphysis.  The  signs  of  such 
an  accident  are  much  the  same  as  the  foregoing. 

Treatment. — The  fractures  which  occur  about  the  shoulder- 
joint  are  extremely  difficult  to  diagnose  with  accuracy;  and 
although  they  have  been  described  under  four  divisions  for  the  sake 
of  clearness,  yet  in  practice  it  is  by  no  means  easy  to  determine 
the  precise  nature  of  the  injury,  and  the  surgeon  must  be  pre- 
pared to  vary  his  appliances  according  to  the  particular  symptoms 
of  the  case,  and  the  age  and  temperament  of  the  patient. 

In  treating    the   first    two    varieties   of  these   fractures,  the 


Fracture 

through  the 

anatomical 

neck. 


Fig.  55. 


Fig.  56. 


Gutta-percha  shoulder-cap. 


Sling  for  the  elbow. 


144 


DISEASES   OF  TISSUES  AND  ORGANS. 


Fig-.  57. 


principal  thing  to  be  attended  to  is  to  keep  the  arm  at  rest,  and 
to  support  it  in  the  natural  position.  With  this  object,  as  soon 
as  the  acute  symptoms  have  been  subdued,  it  is  usual  to 
envelope  the  shoulder  and  upper-arm  in  a  leather  or  gutta- 
percha cap  (Fig.  55),  and  to  place  the  fore-arm  in  a  sling 
which  shall  support  the  elbow  without  pressing  it  upwards 
(Fig.  56).  The  shoulder-cap  should  be  large  enough  to 
fix  the  parts  thoroughly,  and  to  keep  them  perfectly  still. 
To  do  this  it  should  extend  from  the  middle  of  the  clavicle 
nearly  to  the  lower  end  of  the  humerus,  and  should  be  moulded 
upon  the  shoulder  and  arm  in  the  way  described  in  speaking  of 
gutta-percha  splints  in  general  (p.  131). 
It  is  hardly  necessaryto  say  that  such  a 
shoulder-cap  as  this  should  be  lined,  and 
pierced  with  holes  in  the  ordinary  way. 
Some  surgeons  prefer  to  carry  the  gutta- 
percha or  leather  round  the  elbow,  and 
to  make  a  trough  for  the  fore-arm,  con- 
tinuous with  the  cap  for  the  shoulder  and 
upper  arm  (Fig.  57).  But  this  is  seldom 
required,  and  it  always  makes  the  ap- 
paratus more  irksome  to  the  patient. 
The  gutta-percha  splint  should  be  secured 
by  a  light,  cool  bandage  passing  evenly 
round  it  throughout  its  whole  length,  or 
by  ribbons  placed  at  intervals,  or  by 
straps  of  webbing  and  buckles.  The 
upper  arm  should  then  be  bandaged  to 
the  chest,  and  the  fore-arm  comfortably  supported  in  a  sling. 
Sometimes  it  may  be  necessary  to  put  a  pad  in  the  axilla,  to 
assist  in  restoring  the  proper  outline  of  the  shoulder.  But  this 
is  a  point  upon  which  the  surgeon  must  use  his  own  judgment. 

In  almost  all  these  cases,  where  there  is  apt  to  be  pressure 
upon  the  axillary  veins,  either  as  the  consequence  of  inflammation 
about  the  shoulder-jomt,  or  because  of  the  splints  which  it  is 
necessaryto  apply,  it  is  well  to  begin  the  treatment  by  bandaging 
the  arm  evenly  from  the  hand  to  the  fold  of  the  axilla. 

The  last  two  of  the  four  varieties  of  fracture  which  have  been 
enumerated — viz.,  fracture  through  the  surgical  neck,  and  frac- 
ture through  the  epiphysis — generally  present  more  displacement, 
and  require  accordingly  other  appliances.  Here  the  object  is  not 
only  to  keep  the  parts  perfectly  at  rest,  but  also  to  press  the  lower 
fragment  outwards,  for  it  has  a  tendency  to  be  drawn  upwards  and 
inwards  by  muscular  action. 

Fig.  58  was  drawn  from  a  boy,  aged  fourteen,  who  had  met 


Gutta-percha  shoulder 
cap  with  arm-piece. 


FRACTUEES  OF  THE  HUMERUS. 


145 


with  a  fractureof  the  surgical  neck  of  the  humerus.  He  lived  in  a  dis- 
tant part  of  the  country,  far  from  medical  assistance.  No  scientific 
treatment  had  been  adopted,  and  the  natural  displacement  had 
occurred.  When  he  came  to  London  for  advice,  the  fracture  was 
firmly  united,  and  the  wasting  of  the  muscles  from  disuse  allowed  the 
relative  position  of  the  bones  to 
be  seen  with  great  distinctness.         "~-n>^  Fie:.  58 

To  fulfil  the  indications  men- 
tioned above,  it  is  customary  to 
put  a  splint  on  the  outside  of  the 
arm,  long  enough  to  reach  from 
the  shoulder  to  the  elbow,  so  as 
to  fix  the  whole  length  of  the 
humerus.  A  second  shorter  splint 
is  then  placed  on  the  inner  side 
of  the  arm,  so  as  to  push  the 
lower  fragment  outwards,  and 
keep  it  in  its  proper  position; 
and  in  order  to  carry  out  this 
object  more  efficiently  it  may 
be  necessary  to  apply  a  small  pad 
over  the  point  of  fracture.  The 
most  suitable  splints  for  these 
cases  are  the  common  lined 
splints  (see  Fig.  45).  They 
should  be  well  padded  through- 
out, and  the  surgeon  should  see  that  there  is  additional  padding 
over  the  condyles,  so  as  to  prevent  any  undue  pressure  upon  those 
prominences.    Care  must  also  be  taken  that  the  upper  end  of  the 


Fractm-e  of  humerus 
(untreated). 


inner  splint  does  not  gall  the  fold 
of  the  axilla.  The  splints  should 
be  secured  by  bands  of  webbing 
encircling  the  limb,  and  fastened 
on  the  outer  side  by  buckles.  This 
mode  of  retaining  the  splints  in 
their  places  has  the  advantage  of 
being  cool,  and  of  enabling  the 
surgeon  easily  to  undo  the  appara- 
tus, and  examine  the  position  of 
the  broken  bones. 

After  the  splints  have  been  ap- 
plied, the  upper  arm  should  be 
fixed  by  a  few  turns  of  a  bandage 
passing  round  the  chest.  The 
hand  and  wrist  should  then  be  sup- 


Fi°:.  59 


Sling  for  the  fore-ann. 
L 


146  DISEASES  OF  TISSUES  AND  GROANS. 

ported  in  a  sling,  care  being  taken  in  this  case  not  to  include  the 
elbow,  but  to  allow  it  to  hang  down,  so  as  by  its  weight  to 
assist  in  counteracting  the  displacement  upwards  (Fig.  59). 

Some  surgeons  recommend  that  these  fractures  should  be  treated 
by  means  of  a  splint  placed  on  the  outer  side  of  the  arm,  and  a 
pad  in  the  axilla,  to  press  the  lower  fragment  outwards.  Others, 
again,  prefer  a  leather  or  gutta-percha  shoulder-cap,  such  as 
we  have  already  described,  and  a  suitable  pad  under  the  arm. 

FRACTURE    OF    THE    SHAFT   OF    THE 
HUMERUS 

may  be  either  transverse  or  oblique.  When  oblique  they  com- 
monly run  from  above  downwards  and  outwards.  There  is  great 
mobility,  and  crepitus  can  easily  be  produced.  The  displace- 
ment which  occurs  depends  upon  the  precise  seat  of  fracture. 
If  it  is  above  the  insertion  of  the  deltoid,  the  upper  fragment 
is  drawn  inwards  by  the  pectoralis  major  and  associated  muscles, 
while  the  lower  fragment  is  drawn  upwards  and  outwards  by  the 
deltoid.  If  the  point  of  fracture  is  below  the  insertion  of  the 
deltoid,  the  lower  fragment  will  be  drawn  inwards,  while  the 
upper  portion  of  the  bone  is  tilted  outwards. 

Treatment. — Fractures  of  the  shaft  of  the  humerus  are  gene- 
rally treated  by  means  of  wooden  splints.  The  "  common  lined 
splints"  are  the  best ;  but  if  these  are  not  at  hand,  the  ordinary 
straight  ones  will  answer  the  purpose  well  enough.  The  arm 
should  first  be  bandaged  from  the  hand  upwards,  and  then  a 
splint  should  be  placed  on  the  outside,  extending  from  the 
shoulder  to  the  elbow.  A  second  shorter  splint  should  next 
be  fitted  upon  the  inner  side  of  the  arm,  and,  if  need  be,  one  or 
two  smaller  ones  may  be  placed  on  the  anterior  and  posterior 
aspects  of  the  limb  to  counteract  any  special  displacement  that 
may  be  present. 

The  precise  number  of  splints  that  are  reqiiisite  must  depend 
upon  the  circumstances  of  each  individual  case,  and  the  surgeon 
must  use  his  judgment  upon  this  point.  The  size  and  circum- 
ference of  the  limb  will  generally  determine  how  many  are  needed. 
When  the  arm  is  small,  two  will  be  enough  to  embrace  it,  but 
when  it  is  fat  or  muscular,  a  third,  or  even  a  fourth,  will  have  to 
be  employed.  After  the  splints  have  been  adjusted,  the  hand  and 
wrist  should  be  comfortably  supported  in  a  sling. 

Some  surgeons  prefer  to  place  a  rectangular  splint  on  the  inner 
side  of  the  arm.  This  is  an  excellent  method  of  treatment,  par- 
ticularly in  the  case  of  children  or  irritable  patients.  Sometimes 
a  starch  bandage  is  applied  to  the  upper-arm,  especially  when 
satisfectory  union  has  not  been  obtained  in  the  ordinary  period. 


147 


FRACTURES    OF    THS    IiOTVER    EXTREMITT 
OF    THE    HUIMERUS 

may  be  considered  in  a  group.  The  lower  end  of  the  humerus 
may  be  fractured  transversely,  or  obliquely,  above  the  condyles; 
or  either  condyle  may  be  broken  off;  or,  in  children,  the  lower 
epiphysis  may  be  separated  from  the  shaft  of  the  bone. 

In  these  cases  the  fracture  is  often  comminuted  or  compound, 
and  tiot  unfrequently  it  is  associated  with  dislocation.  For  these 
reasons,  and  on  account  of  the  rapid  inflammation  which  sets  in, 
it  is  often  difficult  to  say  what  is  the  precise  nature  of  the  injury, 
but  it  is  sufficiently  evident  that  a  fracture  has  taken  place,  and 
the  treatment  of  all  such  cases  is  much  the  same. 

Treatment. — If  there  is  much  pain,  heat,  and  swelling  about 
the  joint,  we  must  have  recourse  to  fomentations,  cold  lotions, 
leeches,  &c.,  and  the  patient  must  be  kept  in  bed,  with  the  arm 
simply  laid  upon  a  pillow,  until  the  inflammation  has  subsided. 
The  arm  should  be  bent  to  rather  less  than  a  right  angle,  so  as  to 
place  it  in  the  position  that  would  be  most  useful  to  the  patient 
in  the  event  of  ankylosis. 

A  rectangular  splint  should  then  be  applied  on  the  inner  side, 
and  fastened  by  straps  of  webbing  and  buckles,  or  by  a  bandage. 
The  best  kind  of  splint  for  these  fractures  is  a  concave  one  made 
of  iron  or  perforated  zinc,  and  jointed  at  the  elbow,  so  that  it  can 
be  set  at  any  angle  that  may  be  necessary.  Or  two  rectangular 
splints,  made  of  wood,  pasteboard,  leather,  or  gutta-percha,  may 
be  applied,  one  on  each  side  of  the  limb. 

There  is  an  advantage  in  applying  a  splint  only  on  one  side 
of  the  arm,  for  then  the  surgeon  can  easily  watch  the  state  of  the 
part,  and  can  use  any  local  measures  that  may  seem  necessary  to 
subdue  the  inflammation  about  the  joint.  Whatever  splints  are 
employed,  great  care  should  be  taken  that  they  do  not  press  upon 
any  of  the  bony  prominences.  With  this  view  the  padding  should 
be  increased  in  thickness  above  and  below  the  condyles,  so  as  to 
relieve  them  from  the  weight  of  the  splint.  After  the  apparatus 
has  been  adjusted,  the  fore-arm  must  be  supported  in  a  sling. 
At  the  end  of  three  or  four  weeks  passive  movements  should  be 
begun,  to  prevent  ankylosis. 

If  the  fracture  is  compound,  and  the  opening  into  the  joint  is 
but  slight,  an  attempt  may  be  made  to  save  it  by  the  continuous 
application  of  cold,  or  by  antiseptic  treatment ;  but  if  the  joint  is 
freely  opened,  excision — either  primary  or  secondary — will  probably 
have  to  be  performed ;  and  if  the  main  vessels  are  torn,  and  the  soft 
tissues  extensively  lacerated,  amputation  will  have  to  be  considered, 

L  2 


148  DISEASES  OF  TISSUES  AND  OEGANS. 


FRACTURES    OF    THE    FORE-ARM. 

The  olecranon  may  be  broken  either  by  external  violence  or  by 
muscular  action.  Sometimes  the  soft  tissues  are  much  bruised ;  or 
the  fracture  may  be  compound. 

Treatment. — In  simple  fracture  of  the  olecranon  the  arm 
should  be  kept  extended  by  means  of  a  straight  splint  on  the 
anterior  surface.  The  splint  should  be  long  enough  to  reach  from 
the  middle  of  the  upper-arm  to  the  middle  of  the  fore-arm.  It 
may  be  made  of  wood,  or  of  tin,  or  even  of  millboard.  Perhaps 
nothing  is  better  than  a  "common  lined  splint ''  (see  Fig.  45), 
or  an  ordinary  straight  wooden  splint,  bevelled  off  at  the  ends, 
so  as  to  prevent  it  from  galling  the  patient.  But  whatever  kind 
of  splint  is  used,  it  ought  to  be  well  padded.  It  need  not,  however, 
be  burdensome  to  the  patient,  for  its  only  object  is  to  check  the 
movements  of  the  arm,  and  a  very  slight  apparatus  will  be  found 
sufficient  for  this  purpose.  Indeed,  it  is  not  necessary  that  the 
arm  should  be  perfectly  straight.  This  position  is  so  irksome 
that  a  slight  degree  of  flexion  must  be  allowed.  To  meet  this 
the  pad  should  be  graduated  so  as  to  be  thicker  in  the  centre, 
opposite  the  bend  of  the  elbow,  than  at  the  ends.  Some  surgeons 
place  a  small  pad  on  the  back  of  the  arm,  just  above  the  elbow, 
with  a  view  of  drawing  down  the  upper  fragment.  The  splint 
should  be  fastened  near  its  upper  and  lower  ends  either  by  strips 
of  adhesive  plaster,  or  by  tapes,  or  by  pieces  of  webbing  and 
buckles,  or  by  a  bandage.  In  the  simpler  cases  of  fractured 
olecranon  the  splint  should  be  worn  for  about  three  weeks,  and 
then  the  surgeon  should  begin  to  make  passive  movements,  and 
to  encourage  the  patient  to  use  his  arm  by  degrees. 

When  the  soft  tissues  and  the  joint  are  much  implicated,  a  con- 
siderable amount  of  inflammation  will  take  place.  The  patient 
must  be  confined  to  bed,  and  the  arm  treated  with  fomentations, 
lotions,  or  leeches,  before  a  splint  can  safely  be  applied.  While 
this  is  being  done,  the  arm  should  be  laid  upon  a  pillow  in  the 
position  which  is  easiest  to  the  patient,  and  that  will  generally 
be  a  slight  degree  of  flexion.  After  the  inflammation  has  been 
subdued,  a  straight,  well-padded  splint  should  be  placed  on  the 
front  of  the  arm,  and  the  case  treated  as  an  uncomplicated  one — 
only  where  there  has  been  a  high  degree  of  inflammation  the 
surgeon  will  have  to  use  every  effort  to  restore  the  movements 
of  the  joint.  In  some  of  the  most  severe  cases,  where  there  is 
great  probability  of  ankylosis,  it  is  the  best  plan  to  lay  the  arm 
upon  an  angular  splint,  fixed  at  a  little  less  than  a  right  angle. 


FEACTURES   OF  THE  FOEE-AEM. 


149 


But  after  all  our  care,  and  when  the  immediate  union  is  most 
satisfactory,  we  ahnost  always  find  that  the  uniting  medium 
yields  to  the  movements  of  the  arm,  so  that,  in  the  course  of 
time,  an  interval  is  established  between  the  broken  fragments. 
For  this  reason  the  surgeon  will  do  well,  for  his  own  sake,  to 
warn  the  patient  at  the  outset  that  this  is  likely  to  occur. 

In  cases  of  compound  fracture,  with  laceration  of  the  soft  parts, 
excision  of  the  elbow-joint,  or  even  amputation  of  the  arm,  may 
be  necessary. 

Fracture  of  the  middle  of  the  fore-arm. — Both  bones  may  be 
broken,  or  only  one.  When  both  are  broken,  the  displacement 
and  crepitus  make  the  diagnosis  easy.  When  only  one  bone  is 
broken,  it  may  be  more  difiicult  to  determine  the  exact  nature  of 
the  injury.  The  fracture  may  be  either  simple  or  compound. 
In  this  locality  compound  fractures  generally  do  well,  though 
they  are  apt  to  impair  the  power  of  pronation  and  supination. 

Fractures  of  the  radius  alone  are  not  very  uncommon,  but  it  is 
seldom  that  the  ulna  alone  is  broken.  Mr.  Bellamy  has  reported 
the  case  of  a  little  girl,  aged  six,  who  fell  on  the  ulnar  aspect  of 
her  wrist,  and  broke  the  ulna  alone  {Brit.  Med.  Jour.,  Sept. 
16,  1876). 

Treatment. — Fractures  about  the  middle  of  the  fore-arm, 
whether  of  one  or  both  bones,  are  treated  by  placing  the  arm  in 
the  mid-position  between  pronation  and  supination,  and  fixing  a 
straight  splint  on  each  side.  The  splints  should  be  a  little 
broader  than  the  arm,  so  as  to 
prevent  the  injured  parts  from 
being  pushed  together  by  the 
bandage,  and  long  enough  to  ex- 
tend from  the  elbow  to  the  palm, 
so  that  they  may  support  the 
whole  length  of  the  broken  bones. 
Care  should  be  taken  to  maintain 
the  interosseous  space  by  means 
of  a  narrow  pad  laid  along  the 
arm  before  the  splints  are  applied. 
Such  a  pad  may  be  formed  of  a 
few  folds  of  lint,  or  the  ordinary 
padding  of  the  splint  may  be  made 
a  little  thicker  in  the  central  line. 
The  splints  should  be  fixed  by  an 
"  arm  bandage "  carried  round 
them   in  simple  circular  turns,  or  Trougn-shng, 

in  "reverses,"  or  in  a  figure-of-8.  Any  of  these  modes  of  applying 
the  roller  may  be  used,  and  the  one  which  is  found  to  adapt 


Fiff.  60. 


150 


DISEASES  OF  TISSUES   AND   OEGAXS. 


itself  most  evenly  to  the  splints  will  be  tlie  best.  After  the  arm 
has  been  put  up  in  the  way  that  we  have  described,  it  should 
be  carried  in  a  sling  which  will  support  the  whole  length  of  the 
fore-arm  and  hand  (see  Fig.  56),  or  else  in  a  trough  such  as  that 
represented  in  Fig.  60. 

Fracture  of  the  loioer  end  of  the  radius  (Colles's)  is  a  common 
consequence  of  falls  upon  the  hand.  It  must  be  carefully  distin- 
guished from  dislocation  of  the  wrist.  The  latter  is  a  very  rare  acci- 
dent, while  fracture  of  the  lower  end  of  the  radius  is  frequent. 

It  may  be  either  simple,  comminuted,  or  impacted:  and  the 
signs  vary  somewhat  with  the  precise  nature  of  the  injury. 

The  case  from  which  Fig.  61  was  drawn  was  that  of  a  boy,  aged 
sixteen,  and  it  may  be  taken  as  a  typical  example.  There  is  a  dis- 
tinct prominence  on  the  dorsal  aspect,  which  looks  very  much  as  if 
a  dislocation  backwards  had  occurred  at  the  wrist.  Corresponding 
to  this  on  the  palmar  surface  is  a  well-marked  depression,  and 
above  this  again  there  is  another  prominence,  smaller  and  less 
distinct  than  that  on  the  dorsal  aspect.  The  hand  is  thrown  a 
little  towards  the  radial  side,  and  the  styloid  process  of  the  ulna 
becomes  remarkably  prominent. 


Fig.  61. 


Colles's  fracture  of  the  radius. 

The  prominence  on  the  dorsal  aspect  is  due  to  the  lower  frag- 
ment of  the  radius,  which  is  thrown  backwards  on  to  the  lower  end 
of  the  upper  fragment,  carrying  the  carpus  along  with  it.  This 
also  explains  the  palmar  depression.  Tlie  prominence  on  the  palmar 
aspect  is  caused  by  the  lower  end  of  the  upper  fragment.  The 
obliquity  of  the  hand  and  the  projection  of  the  styloid  process  of 
the  ulna  are  due  to  muscular  action,  and  are  brought  about  by  the 
contraction  of  the  supinator  longus,  the  extensors  of  the  wrist,  and 
the  pronator  quadratus. 

This  accident  is  accompanied  by  loss  of  power,  particularly  in 
supination,  and  great  pain.  In  the  Lancet  of  June  28,  1873,  I 
have  related  the  case  of  a  woman  who  fell  down  a  flight  of  stairs, 
and  simultaneously  fractured  the  lower  ends  of  both  her  radii. 
She  made  a  good  recovery.     Her  arms  were  afterwards  strong. 


FRACTUllES  OF   THE   FOEE-ARM. 


151 


and  the  movements  almost  perfect,  so  that  she  was  able  to  return 
to  her  work  as  a  charwoman. 

Treatment. — Extension  must  be  made  so  as  to  bring  the 
fragments  as  far  as  possible  into  their  proper  places,  and  then 
the  hand  should  be  bent  strongly  over  towards  the  ulnar  side. 
In  this  position  it  is  to  be  fixed  by  means  of  a  "  pistol  splint" 
(Fig.  62) — i.e.,  a  straight  splint  bent  downwards  at  one  end  so 

Fig.  62. 


Pistol-splint, 
as  to  adapt  it  to  the  shape  of  the  fore-arm  and  hand,  when  the 
latter  is  turned  somewhat  obliquely.  The  splint  should  be  long 
enough  to  reach  from  the  elbow  to  the  roots  of  the  fingers.  It 
is  desirable  that  it  should  not  extend  further,  so  as  to  allow  the 
patient  to  move  his  fingers.  It  is  generally  placed  on  the 
anterior  aspect  of  the  limb,  but,  if  need  be,  it  may  be  applied  on 
the  posterior,  and  it  should  be  secured  by  means  of  an  "  arm- 
bandage."  If  necessary,  a  second  straight  splint  may  be  laid 
along  the  opposite  side  of  the  arm ;  and  pads  may  be  used  to  make 
pressure  upon  the  prominences,  so  as  to  keep  the  fragments  of 
bone  in  their  proper  positions.  The  arm  must  be  carried  in  a 
sling  or  trough. 

This  is  the  usual  way  of  deahng  with  an  ordinary  case  of 
Colles's  fracture  ;  but  if  a  "  pistol-splint"  is  not  at  hand,  the 
case  may  be  treated  perfectly  well  by  two  straight  splints,  such 

Fiff.  63. 


Splint  for  the  hand  and  arm. 

as  are  used  for  fractures  of  the  middle  of  the  fore-arm.  This 
plan  has  the  advantage  of  being  less  irksome  to  the  patient  than 
the  constrained  position  which  the  "  pistol- splint"  involves.  But 
it  is  always  well  to  warn  the  patient  that,  whatever  mode  of 
treatment  is  adopted,  some  degree  of  deformity  and  stiffness  will 
almost  invariably  remain  after  this  accident. 


152 


DISEASES   OF  TISSUES   AND  OEGANS. 


Fractures  of  the  metacarpal  hones  and  phalanges  are  generally 
easily  detected  by  the  history  of  the  injury,  loss  of  power,  pain, 
and  crepitus. 

Treatment. — The  best  mode  of  treating  a  fracture  of  the  meta- 
carpal bones  is  by  laying  the  extended  hand  upon  a  wooden  or 
gutta-percha  splint  cut  to  the  shape  of  the  part  (Fig.  63). 

The  surgeon  should  bear  in  mind  that  the  palmar  aspect  of 
these  bones  is  concave,  and  he  should  have  the  splint  well-padded 
so  that  it  may  adapt  itself  to  their  form.  It  is  often  recom- 
mended to  treat  the  central  metacarpal  bones  by  binding  the 
hand  over  a  ball  of  lint  or  tow.  These  bones  are  so  well  pro- 
tected by  Nature  that  a  very  little  padding,  judiciously  placed, 
keeps  them  in  their  proper  position.  If  one  metacarpal  bone  only 
is  broken,  it  may  suffice  to  lay  a  narrow  strip  of  wood  along  it, 
reaching  from  the  point  of  the  finger  to  a  short  distance  above 
the  wrist.  This  may  be  laid  either  along  the  palmar  or  the 
dorsal  aspect,  and  may  be  secured  by  strips  of  adhesive  plaster. 

When  the  phalanges  are  broken  they  should  be  treated  by  lay- 
ing the  finger  upon  a  narrow  splint  of  wood,  or  millboard,  or 
gutta-percha.  If  the  injury  is  very  severe,  and  several  fingers 
are  involved,  it  may  be  needful  to  lay  the  whole  hand  flat  upon  a 
wooden  splint  cut  to  the  shape  of  the  thumb  and  fingers  (see  Fig. 
63).  Here,  also,  the  surgeon  should  bear  in  mind  that  the  palmar 

aspect  of  the  bones  is  concave, 
^  ig.  d4:.  j^j^^  arrange  the  pad  accord- 

ingly. If  the  injury  is  com- 
pound, and  an  operation  is 
necessary,  as  little  as  possible 
should  be  taken  away.  The 
vitality  of  the  tissues  is  great : 
they  do  not  readily  slough, 
and  every  portion  which  is 
left  may  in  due  time  add  to 
the  usefulness  of  the  organ. 
In  all  these  cases  the  arm 
should  be  supported  in  a  sling 
so  disposed  as  to  raise  the  hand 
above  the  level  of  the  elbow. 

After  these  fractures,  as  well 
in    various    other    conditions, 
i  t  is  desirable  to  bandage  the  hand  and  arm.     We  shall  therefore 
take  this  opportunity  of  explaining  how  it  ought  to  be  done. 

Bandage  for  the  hand  and  arm. — A  narrow  roller  is  carried 
in  a  figure-of-8  round  the  hand  and  wrist — one  loop  including 
the  hand  and  the  other  the   wrist,  and  the  thumb  protruding 


Bandage  for  the  hand. 


FRACTUEES   OF  THE  FEMUR. 


153 


The  bandage  may  then  be  con- 
Fig.  G5. 


between  the  folds  (Fig.  64). 
tinned  for  some  little 
distance  up  the  arm,  in 
simple  circular  turns ; 
but  as  soon  as  it  reaches 
the  point  where  the  limb 
begins  to  enlarge,  "re- 
verses," or  figures-of-8, 
must  be  made,  so  as  to 
insure  its  fitting  closely 
and  evenly  (Fig.  65). 

Such  a  bandage  as  this 
may  be  very  conveniently 
fastened  by  tearing  the 
extremity  down  the  mid- 
dle to  a  sufficient  extent, 
and  then  turning  the  two 
ends  round  the  part  in 
opposite  directions,  and  tying  them  in  a  knot  or  in  a  bow. 


Bandage  for  the  hand  and  arm. 


FRACTURBS  OF  THB  PZIiVIS 

are  often  complicated  with  injury  to  internal  organs,  and  this 
makes  them  very  serious.  Most  frequently  it  is  the  front  or  the 
back — the  rami  of  the  pubes  or  ischium,  or  the  sacro-iliac  articu- 
lation— which  is  broken. 

Signs. — Pain,  inability  to  stand  or  walk,  unnatural  mobility, 
and  crepitus.  The  history  of  the  injury  by  great  and  direct 
violence  is  an  important  aid  to  the  diagnosis. 

The  complications  which  are  most  likely  to  arise  are  rupture  of 
the  bladder,  or  urethra,  with  extravasation  of  urine,  laceration  of 
the  rectum,  or  fracture  through  the  acetabulum. 

Treatment. — A  catheter  should  be  passed  to  ascertain  the 
state  of  the  urethra  and  bladder.  A  broad  bandage,  or  a  padded 
belt,  should  be  applied  round  the  hips,  the  knees  should  be  tied 
together,  and  the  patient  kept  perfectly  quiet.  If  the  urethra 
has  been  lacerated,  there  will  be  extravasation  of  urine,  and  some 
of  the  measures  mentioned  under  that  heading  will  have  to  be 
adopted  (see  p.  311).  After  all,  it  is  probable  that  a  trouble- 
some stricture  will  be  left. 

FRACTURES  OF  TKS  FE»X17R 

may  be  considered  under  three  divisions — those  of  the  upper 
extremity  of  the  bone,  those  of  the  shaft,  and  those  of  the  lower 
extremity. 

In  every  case  of  fracture  of  the  lower  limb  the  patient  should 


154  DISEASES  OF  TISSUES  AND   OEGANS. 

be  laid  on  a  flat,  hard  bed.  Xothin^  is  better  tban  a  bair 
mattress,  placed  upon  tbe  framework  of  tbe  bed,  or  upon  a  straw 
palliasse.  Sometimes  flat  pieces  of  wood,  about  six  or  seven 
incbes  broad — commonly  known  as  "  fracture  boards" — are  laid 
side  by  side  across  tbe  bedstead,  so  as  to  form  a  firm,  even  surface 
for  the  mattress  to  rest  upon. 

In  fractures  of  the  lower  extremity  sand-bags  are  often  of 
great  use  to  the  surgeon.  These  are  cylindrical  pillows,  four  or 
five  inches  in  diameter,  and  two  or  three  feet  in  length,  filled 
with  dry  sand.  The  pillow  case  should  be  made  of  strong  calico 
or  ticking,  and  covered  first  with  waterproof  cloth,  and  then  with 
flannel. 

Feactuees  op  the  Uppee  Exteemity  op  the  Femtje. — 
The  fractures  which  occur  about  the  head  and  neck  of  the 
femur  are  often  extremely  difficult  to  diagnose  with  accuracy. 
We  shall,  however,  for  the  sake  of  convenience,  follow  the  usual 
classification,  and  divide  them  into  intra-capsular  and  extra- 
capsular. In  either  case  the  fracture  may  be  simple  or  com- 
pound. 

Intra-capsular  fracture  of  the  necTc  of  the  thigh-hone. — This 
accident  is  almost  peculiar  to  persons  over  fifty.  It  is  more  com- 
mon in  women  than  in  men,  and  arises  from  very  slight  causes, 
such  as  tripping  on  the  carpet,  or  stumbling  over  a  stone. 

As  age  advances,  the  neck  of  the  bone  becomes  more  horizontal 
in  position,  so  that  the  weight  of  the  body  falls  more  directly 
upon  it.  The  bone-tissue  itself  also  undergoes  changes.  The 
caucelli  become  enlarged,  and  filled  with  fatty  matter  ;  while  the 
compact  tissue  is  absorbed,  until  nothing  is  left  but  a  mere  shell. 

Signs. — Pain,  loss  of  power,  crepitus,  absence  of  the  natural 
prominence  of  the  trochanter,  shortening  and  eversion  of  the  leg ; 
but  if  there  is  any  degree  of  impaction  these  signs  may  be  some- 
what obscured.  Pain  on  pressure  over  the  front  of  the  hip- 
joint  gives  a  presumption  of  intra-capsular  fracture.  It  is  im- 
portant to  observe,  as  Mr.  Canton  has  pointed  out,  that  distinct 
shortening,  the  result  of  absorption,  may  follow  a  severe  blow 
upon  the  hip,  without  fracture. 

Union  may  take  place  by  bone,  but  this  is  an  extremely  rare 
occurrence.  In  the  vast  majority  of  cases  the  union  is  fibrous. 
'J'his  arises  partly  from  a  want  of  perfect  apposition  between  the 
fragments,  and  partly  from  the  very  scanty  supply  of  blood  which 
the  head  receives  through  the  vessels  of  the  ligamentum  teres. 
When  bony  union  takes  place,  it  is  probable  that  the  fracture  has 
been  impacted,  as  in  Fig,  66,  which  was  drawn  from  a  prepara- 
tion in  the  museum  of  Charing  Cross  Hospital. 

Treatment. — In  these  fractures  it  is  seldom  necessary  to  use 


FRACTUEES   OF  THE  FEMUK. 


155 


ff.  66. 


Impacted  fracture  of  the  neck  of  the 
femur. 


any  splint.  As  the  subjects  of  this  injury  are  almost  always  aged, 
and  as  bony  union  is  hardly  to  be  expected,  it  would  be  useless, 
and  even  dangerous,  to 
confine  them  to  bed  for 
any  length  of  time.  The 
patient  should,  therefore, 
be  kept  in  the  recumbent 
position  fov  ten  days  or  a 
fortnight,  until  the  in- 
flammatory symptoms 
have  subsided,  and  then 
be  allowed  to  get  up  and 
move  about  on  crutches. 
He  will  probably  be  more 
or  less  lame  for  the  rest 
of  his  life,  but  with  the 
help  of  a  stick  he  will  be 
able  to  walk  about  with 
ease. 

Hxtra-capsular  fracture  of  the  neck  of  the  thigh-hone  is 
usually  the  result  of  great  and  direct  violence.  It  generally 
happens  before  the  age  of  fifty. 

The  signs  are  much  the  same  as  in  the  foregoing  injury,  only 
they  are  more  strongly  marked.  Pain  on  pressure  over  the 
great  trochanter  gives  a  presumption  of  extra-capsular  fracture. 

The  injury  is  often  associated  with  fracture  through  the 
trochanter,  and  there  is  always  much  bruising  and  swelling  of 
the  hip.  In  the  case  of  extra-capsular  fracture  we  aim  at 
obtaining  body  union. 

Treatment. — A  broad  bandage  should  be  passed  round  the 
hips  so  as  to  prevent  movement  between  the  fragments.  The 
limb  should  then  be  extended,  and  fixed  in  that  position  by  means 
of  "  Liston's  long  splint ;"  or  both  legs  should  be  flexed,  and 
laid  upon  a  double-inclined  plane.  These  methods  will  be  ex- 
plained at  length  in  the  next  Section. 

FEACTrEES  OF  THE  Shaet  OP  THE  Femije  are  of  very  com- 
mon occurrence,  and  can  generally  be  recognised  without 
difficulty. 

Signs. — There  is  pain,  loss  of  power,  crepitus,  shortening,  and 
eversion.  The  lower  fragment  is  drawn  upwards  and  inwards 
by  the  action  of  the  adductors;  and,  if  the  fracture  is  high  up, 
the  upper  fragment  is  tilted  forwards  by  the  psoas  and  iliacus, 
and  outwards  b^  the  external  rotators.  Indeed,  oblique  frac- 
tures at  the  upper  part  of  the  femur  are  often  difficult  to  treat, 
and  leave  a  weak  limb  for  a  length  of  time. 


156 


DISEASES  OF  TISSUES  AND  OEGANS. 


The  treatment  may  be  conducted  either  by  means  of  a  long 
splint  or  a  double-inclined  plane.  The  latter  is  particularly 
useful  in  cases  where  the  upper  fragment  is  tilted  forwards ;  but 
the  former  is  more  suitable  to  the  majority  of  cases.  The  most 
convenient  long  splint  is  Liston's.  The  surgeon  who  is  about  to 
use  it  should  be  provided  with  a  piece  of  strong  tape,  or  a  silk 
pocket-handkerchief,  long  enough  to  pass  from  tiie  upper  end  of 
the  splint  round  the  perineum  to  the  same  point,  and  to  be  there 
tied  in  a  bow.  The  "  perineal  band,"  as  this  appliance  is  called, 
should  be  well  padded  at  the  part  where  it  presses  upon  the 
perineum,  so  as  to  prevent  it  from  cutting  the  skin ;  and  care 
must  be  taken,  particularly  in  the  case  of  children,  that  it  is 
kept  scrupulously  clean.  The  splint  should  be  long  enough  to 
reach  from  the  fold  of  the  axilla  to  about  four  inches  below  the 
foot.  It  should  be  pierced  with  two  holes  near  its  upper  end, 
and  at  its  lower  end  it  ought  to  be  deeply  notched  in  the  manner 
indicated  in  the  accompanying  illustration  (Fig.  67).     It  should 

Fig.  67. 


Fracture  of  the  thigh :  Liston's  long  splint. 

be  well  padded,  and  it  is  advisable  to  carry  the  pad  over  the 
upper  end  of  the  splint,  so  as  to  prevent  it  from  galling  the  skin  of 
the  axilla.  The  pad  should  be  pierced  with  two  holes  corresponding 
to  those  of  the  splint,  so  that  the  perineal  band  may  slip  through 
it  easily,  and  be  loosened  or  tightened  at  pleasure. 

In  applying  the  apparatus,  the  surgeon  first  of  all  takes  the 
padded  portion  of  the  perineal  band  and  adjusts  it  to  the  patient's 
perineum,  bringing  up  one  end  in  front  and  the  other  behind. 
He  then  lays  the  splint  along  the  outer  side  of  the  aifected  limb, 
and  fastens  the  foot  to  the  lower  end  of  it.  In  doing  this  it  is  a 
good  plan  first  to  bandage  the  foot  and  ankle  in  the  ordinary  way, 
to  protect  them  from  the  pressure  of  the  splint,  and  to  prevent 
them  from  swelling  ;  or  instead  of  this,  the  foot  may  be  enveloped 
in  a  layer  of  cotton-wool.  The  surgeon  should  then  take  a  "  leg 
bandage,"  and  make  a  few  turns  round  the  foot  and  ankle  in  the 
form  of  a  figure-of8,  so  as  to  obtain  a  firm  hold;  after  which 
he  should  carry  the  roller  in  a  regular  way  round  the  ankle,  and 


FEACTURES  OF  THE  FEMUE.  157 

through  the  notches  in  the  lower  end  of  the  splint,  so  as  to  fasten 
it  securely  to  the  foot.  He  should  then  get  an  assistant  to  make 
extension  from  the  foot  while  he  draws  the  perineal  band  tight, 
and  ties  it  in  a  bow  on  the  outer  side  of  the  splint.  In  order  to 
keep  the  apparatus  in  position,  it  is  sometimes  necessary  to  apply 
a  bandage  over  both  the  leg  and  the  splint,  and  also  to  put  a  few 
turns  of  a  broad  roller  round  the  pelvis  and  chest. 

When  the  fracture  runs  through  the  great  trochanter  or  the 
upper  part  of  the  shaft  of  the  femur,  without  involving  the  neck, 
the  upper  fragment  of  the  bone  is  apt  to  be  tilted  forward  by 
muscular  action,  as  we  have  already  explained.  If  Liston's 
long  splint  is  used  for  a  case  of  this  kind,  it  may  be  necessary 
to  apply  a  short,  well-padded  splint  on  the  front  of  the  thigh, 
to  counteract  any  special  displacement  that  may  exist.  But  it 
is  better  to  adopt  some  other  method  of  treatment.  Thus,  the 
surgeon  may  lay  the  limb  on  its  outer  side,  flexing  the  leg  upon 
the  thigh  and  the  thigh  upon  the  pelvis,  and  supporting  it  upon  a 
broad  angular  splint  of  wood  or  gutta-percha.  By  this  means 
the  muscles  are  relaxed,  and  the  fragments  brought  into  apposi- 
tion. Some  cases  do  best  on  the  double-inclined  plane.  The 
most  convenient  contrivance  of  this  sort  is  that  which  we  have 
here  figured  (Fig.  68).     By  this  means  a  ridge  is  formed  in  the 

Fig.  68. 


Double-inclined  plane. 

middle  of  the  bed  over  which  the  patient's  legs  are  laid.  This 
has  the  eifect  of  bringing  the  broken  fragments  of  the  femur 
into  apposition,  and  nothing  more  is  needed  than  to  maintain  the 
same  posture  until  union  has  taken  place.  A  double-inclined 
plane  may  easily  be  extemporized  by  nailing  two  pieces  of  wood 
together  at  a  suitable  angle,  or  even  by  an  arrangement  of  pillows. 
In  some  of  these  cases  the  suspensory  method  of  treatment,  which 
used  formerly  to  be  employed,  and  which  has  lately  been  revived  in 
a  modified  form  by  Dr.  Nathan  Smith,  of  Baltimore,  may  be  used 
with  advantage  (see  Fig.  70). 

If  the  perineum  becomes  excoriated,  extension  may  be  made 
from  the  opposite  thigh  by  placing  a  collar  of  adhesive  plaster, 


158 


DISEASES  OF  TISSUES  AND  OEGANS. 


or  a  padded  belt,  round  it,  and  carrying  tapes  from  this  to  the 
holes  at  the  upper  end  of  the  long  splint. 

In  treating  fractures  of  the  femur  a  great  deal  may  be  done  by 
simply  attending  to  the  position  of  the  limb  without  the  applica- 
tion of  any  splint.  Thus,  if  the  patient  has  a  sufficient  amount  of 
self-control,  he  may  be  laid  flat  on  his  back,  the  hollows  under  the 
leg  and  thigh  padded  with  cotton- wool,  so  as  to  bring  the  broken 
fragments  into  their  proper  line,  and  then  a  sand-bag  placed  on 
each  side  of  the  limb.  If,  in  addition  to  this,  the  whole  is  encircled 
with  two  or  three  pieces  of  tape,  an  efficient  apparatus  will  be 
formed,  which  is  as  little  irksome  to  the  patient  as  anything  of 
the  kind  can  be.  If  sand-bags  are  not  at  hand,  their  place  may 
be  supplied  by  a  bundle  of  clean,  dry  straw,  wrapped  in  a  sheet, 
or  by  any  other  suitable  material  which  will  give  the  necessary 
amount  of  support,  and  accommodate  itself  to  the  shape  of  the  limb. 

Sometimes — more  particularly  in  the  case  of  children^f-exten- 
sion  may  conveniently  be  made  by  fastening  a  loop  of  plaster 
under  the  foot,  and  attaching  a  weight  to  it — the  weight  being 
allowed  to  hang  over  the  end  of  the  bed.  The  surgeon  should 
take  a  long  strip  of  plaster,  lay  it  along  one  side  of  the  leg,  pass  it 
loosely  under  the  sole,  and  bring  it  up  on  the  other  side  of  the 
leg.  He  should  then  encircle  the  leg  in  two  or  three  places  with 
strips  of  plaster  passing  round  it  transversely ;  and  over  all  he  may, 
if  he  thinks  it  necessary,  apply  a  bandage  in  the  way  represented 
in  Fig.  69.     By  this  arrangement  a  loop  is  left  underneath  the 


Fig.  69. 


Bandage  for  extension. 


sole  which  draws  upon  the  whole  length  of  the  leg,  and  the  pres- 
sure does  not  fall  upon  any  one  point,  so  that  the  risk  of  irritat- 
ing the  skin,  or  producing  rodema  of  the  foot,  is  greatly  reduced. 
The  weight  need  not  be  so  heavy  as  to  distress  the  patient. 
All  that  is  needed  is  that  it  should  make  a  slight  but  constant 


FRACTURES   OF  THE  FEMUR.  159 

traction  upon  the  limb.  It  is  a  good  plan  to  take  a  bag  and  pour 
dry  sand  into  it,  such  as  is  used  for  making  sand-bags,  adding 
a  little  each  day,  as  the  patient  is  able  to  bear  it,  until  the  proper 
weight  has  been  attained.  Or  the  bag  may  be  tilled  with  shot, 
or  any  other  heavy  substance ;  or  the  ordinary  iron  weights,  which 
are  furnished  with  a  ring  on  the  upper  surface,  may  conveniently 
be  used.  By  a  simple  apparatus  of  this  kind,  and  by  placing 
sand- bags  on  either  side  of  the  leg,  splints  may  sometimes  be  dis- 
pensed with  altogether  for  young  subjects.  The  same  method  is 
found  of  great  service  in  deahng  with  diseases  of  the  hip  and 
knee.  The  bones  are  kept  apart,  so  that  the  patient  is  saved 
from  much  of  the  pain  that  they  cause  by  rubbing  against  one 
another,  and  the  limb  is  maintained  in  good  position  in  case 
ankylosis  should  occur. 

The  apparatixs  which  Dr.  Nathan  Smith  has  introduced  for 
treating  fractures  of  the  femur,  among  its  other  advantages,  is 
particularly  suitable  to  cases  in  which  the  back  of  the  limb  has  been 
much  bruised.  It  consists  of  a  couple  of  light  iron  rods,  bent  at 
such  an  angle  as  to  suit  the  shape  of  the  thigh  and  leg  when 
slightly  flexed  (Fig.  70).     The  rods  are  connected  together  at 

Fig.  70. 


Nathan  Smith's  anterior  splint. 

their  lower  end,  and  a  space  is  left  between  them  sufficient  to 
receive  the  limb.  From  one  end  to  the  other  strips  of  bandage 
are  fastened  transversely,  side  by  side,  so  as  to  form  a  trough, 
fitted  to  the  shape  of  the  leg  and  thigh.  Upon  this  the  limb  is 
laid,  and  then  the  rods  are  attached  to  cords  which  are  suspended 
from  a  point  above  the  bed,  and  which  are  regulated  by  pulleys. 
The  hook  to  which  the  cords  are  fastened  ought  to  be  placed,  not 
immediately  over  the  limb,  but  a  little  in  front  of  it,  so  as  to 
make  extension,  while  the  weight  of  the  patient's  body  supplies  a 
counter-extending  force.  This  apparatus  has  the  merit  of  being 
remarkably  simple,  cheap,  and  clean.  Moreover,  it  enables  us  to 
swing  the  whole  of  the  lower  extremity,  and  to  give  the  thigh 
some  of  that  relief  which  we  can  afford  to  the  knee  and  the  leg 
by  means  of  "  Salter's  Swing"  (see  Fig.  80). 

After  the  patient  has  been  treated  by  any  of  these  methods  for 
five  or  six  weeks,  a  flannel  bandage,  or  a  starch  bandage,  should 
be  applied,  and  he  should  be  allowed  to  move  about  on  crutches. 


160 


DISEASES   OF  TISSUES  AND  OEGANS. 


Fiar.  71. 


Mr.  Erichsen  and  other  surgeons  treat  fractures  of  the  femur  by 
simply  confining  the  }  atient  to  bed  for  a  few  days,  and  then 
putting  up  the  whole  leg  and  thigh  in  a  starch  bandage.  This 
method  has  the  advantage  of  permitting  the  patient  to  go  about 
on  crutches  while  union  is  taking  place.  At  the  same  time  there 
is  more  risk  of  malposition  than  when  the  patient  is  confined  to 
bed  until  consolidation  has  taken  place.  It  must  also  be  borne 
in  mind  that  the  femur  is  one  of  those  bones  in  which  non-union 
is  apt  to  occur,  and  where  it  is  especially  desirable  that  the  frag- 
ments should  be  kept  at  rest  and  in  apposition. 

In  cases  of  compound  fracture  of  the  femur  the  course  which 
must  be  adopted  depends  entirely  upon  the  extent  and  severity 
of  the  wound.  When  this  is  slight,  the  limb  may  be  put  up  in 
the  way  described  already,  and  the  wound  sealed,  or  treated  on 
antiseptic  principles.  But  when  the  main  vessels  are  torn,  or  when 
the  injury  to  the  soft  parts  is  very  extensive,  the  question  of 
amputation  will  have  to  be  considered  (see  p.  61). 

Fractijees  of  the  Lower  Extremity  op  the  Feiiur 
may  be  either  transverse  or  oblique.     When  transverse,  they 

generally  occur  in  young  subjects, 
and  follow  the  hne  of  the  epiphysis. 
When  oblique,  they  are  apt  to 
extend  into  the  joint.  Fig.  71 
shows  such  a  fracture.  A  section 
has  been  made  through  the  con- 
dyle, and  it  will  be  seen  that 
inflammation  has  commenced  in 
the  cancellous  tissue. 

Treatment. — When  the  femur 
is  broken  near  its  lower  end, 
great  care  should  be  taken  to 
keep  the  limb  at  rest  so  as  to 
prevent,  as  far  as  possible,  any 
inflammation  of  the  knee-joint. 
The  simpler  cases  of  this  kind 
may  be  treated  by  means  of 
Listen's  long  splint  and  a  perineal  band  (see  p.  156).  But  if 
the  injury  is  more  severe,  or  if  the  patient  is  restless,  it  is  better 
to  put  the  limb  upon  a  "  M'Intyre's  splint"  (see  Fig.  74),  which 
gives  perfect  support  to  both  the  thigh  and  the  leg,  while  it  pre- 
vents any  movement  at  the  knee-joint.  If  the  limb  is  slightly 
flexed  upon  the  splint,  and  then  laid  in  a  "  Salter's  Swing,"  it 
will  give  the  patient  great  comfort,  and  afibrd  him  the  best 
chance  of  a  good  recovery.  It  must  be  remembered  that  in  a 
severe  case  of  this  kind  ankylosis  may  take  place,  and  that  in 


Fracture  into  the  knee-joint. 


FRACTURE  OF  THE  PATELLA.       161 

such  an  event  a  slight  degree  of  flexion  at  the  knee  is  the  posi- 
tion which  will  leave  the  patient  the  most  serviceable  limb. 

If  the  fracture  is  compound,  and  the  joint  opened,  the  case 
will  probably  require  immediate  amputation. 

FRACTURE  OF  THE  PATEXiIiA. 

The  patella  may  be  broken  either  by  direct  violence  or  by 
muscular  action.  When  it  is  broken  by  direct  violence  the 
fracture  may  take  any  direction,  or  it  may  be  comminuted. 
When  it  is  the  result  of  muscular  accion,  it  is  always  transverse. 
The  bone  being  fixed  below  by  the  ligaraentum  pitellae,  and 
stretched  upon  the  condyles  of  the  femur  at  the  moment  when 
the  leg  is  bent,  the  violent  contraction  of  the  extensors  tears  it 
across.  The  accident  generally  occurs  in  the  sudden  effort  made 
by  a  person  to  save  himself  from  falling  backwards,  I  have 
known  a  gentleman  slip  in  frosty,  weather  and  break  both  his 
patellae  transversely  at  the  same  moment. 

Signs. — Inability  to  stand,  or  to  extend  the  joint,  and  crepitus. 
The  line  of  fracture  may  be  felt ;  if  it  is  transverse,  the  frag- 
ments are  widely  separated. 

The  kind  of  union  which  results  varies  with  the  nature  of  the 
accident.  If  the  fracture  is  longitudinal  or  comminuted,  union 
takes  place  by  bone ;  but  when  the  fracture  is  transverse,  the 
union  is  almo.st  always  fibrous.  The  chief  reason  for  this  is  that 
in  the  former  class  of  cases  it  is  generally  easy  to  keep  the  frag- 
ments in  apposition ;  while  in  the  latter  we  always  find  that 
there  is  such  a  wide  interval  between  the  pieces  of  bone  that  it 
is  very  difficult  to  bring  them  together,  and  to  retain  them  in  that 
position. 

The  treatment  of  the  longitudinal  and  comminuted  fractures 
consists  simply  in  extending  the  leg  upon  a  light  wooden  back- 
splint,  and  then  relaxing  the  extensor  muscles  of  the  thigh  by 
propping  the  patient  up  in  bed  with  pillows,  so  as  to  place  him  in 
the  semi-recumbent  position ;  or — which  has  the  same  effect — 
by  laying  him  nearly  flat,  and  raising  the  limb  upon  pillows  or  in 
a  swing,  so  as  to  flex  the  thigh  on  the  pelvis.  When  one  posi- 
tion becomes  irksome,  it  may  be  exchanged  for  the  other;  or  one 
may  be  maintained  during  the  day,  and  the  other  at  night ;  care 
being  taken  always  to  preserve  the  same  angle  at  the  hip,  so  that 
the  extensor  muscles  of  the  thigh  may  be  kept  constantly  relaxed. 
If  there  is  much  swelhng  or  inflammation  about  the  joint,  or  if 
the  soft  tissues  are  extensively  bruised,  it  may  not  be  advisable  to 
apply  a  back-splint  at  once.  In  such  a  case  the  leg  should  be 
simply  laid  upon  a  pillow,  and  treated  with  cooling  lotions  or 
with  fomentations  until  the  acute  symptoms  have  subsided ;  and 

M 


162  DISEASES  OF  TISSUES  AND  OEGANS. 

then  the  limb  may  be  put  upon  a  splint.  If  there  is  any  fear 
of  ankylosis,  the  surgeon  should  bear  in  mind  that  the  most  use- 
ful position  for  the  patient  is  that  in  which  the  leg  is  slightly 
flexed. 

The  treatment  of  transverse  fractures  is  less  satisfactory.  In  a 
case  of  this  kind  the  patient  should  be  laid  in  one  of  the  positions 
that  we  have  already  described,  so  as  to  relax  the  muscles,  and 
allow  the  broken  fragments  of  bone  to  approach  one  another.  If 
there  is  much  inflammation  about  the  knee- joint,  it  may  be  im- 
possible to  do  more  than  this  for  a  few  days.  Fomentations  or 
cooling  lotions  must  be  constantly  applied.  After  the  swelling 
has  been  subdued,  it  is  well  to  extend  the  leg  upon  a  back-splint. 
A  concave  one  made  of  wood  is  perhaps  the  best  that  can  be  em- 
ployed. It  ought  to  be  long  enough  to  reach  from  the  middle  of 
the  thigh  to  the  middle  of  the  leg,  and  it  should  be  well  padded. 
It  may  be  fastened  either  witU  broad  strips  of  plaster,  or  with  a 
few  turns  of  a  bandage,  at  its  upper  and  lower  end — the  seat  of 
fracture  being  left  uncovered.  These  simple  means  often  suffice 
to  bring  the  broken  fragments  nearly  together ;  and  although  a 
great  deal  of  ingenuity  has  been  expended  upon  the  treatment  of 
these  injuries,  it  is  a  question  whether  any  better  or  safer  method 
than  this  has  been  devised. 

If,  however,  the  surgeon  is  anxious  to  try  and  bring  the  frag- 
ments into  closer  apposition,  there  are  a  variety  of  means  at  his 
disposal.  In  addition  to  the  back-splint  he  may  place  a  collar  of 
adhesive  plaster  round  the  thigh,  attach  tapes  or  elastic  bands 
to  each  side  of  it,  and  carry  them  down  and  fasten  them  to  a 
slipper  on  the  foot,  or  connect  them  with  weights,  and  suspend 
them  over  the  end  of  the  bed.  The  collar  plaster  should  be 
about  two  inches  broad,  and  should  overlap  the  upper  fragment 
of  the  patella,  so  that  the  traction  may  be  exerted  upon  the  broken 
bone,  and  not  merely  upon  the  skin.  Or  he  may  endeavour  to 
draw  the  upper  fragment  downwards  by  a  figure-of-8  bandage 
applied  over  the  back-splint,  and  the  effect  of  such  a  bandage  will 
be  considerably  increased  if  a  pad  of  lint  is  laid  upon  the  upper 
edge  of  the  upper  fragment.  This  pad  may  be  fixed  in  its 
place  by  a  strip  of  adhesive  plaster,  and  then  the  roller  applied 
over  it.  Mr.  John  Wood  has  devised  a  splint  for  these  cases, 
which  gives  the  figure-of-8  bandage  a  better  hold,  and  increases 
its  power.  It  consists  simply  of  a  straight  concave  iron  splint 
furnished  with  two  hooks  behind  the  knee.  The  hooks  are 
placed  back  to  back,  and  at  such  a  distance  from  one  another  as 
to  give  the  bandage  a  suitable  degree  of  obliquity.  The  same 
principle  has  been  applied  yet  more  simply  by  cutting  notches  in 
the  sides  of  a  straight  wooden  splint,  and  fixing  the  loops  of  the 


FRACTURE  OF  THE  PATELLA.       163 

figure-of-8  bandage  upon  them  (see  Hamilton  on  Fractures). 
When  any  apparatus  of  this  kind  is  used,  or  when  any  bandage  is 
applied  which  compresses  the  limb,  care  must  be  taken  to  cover 
the  leg  with  a  roller  from  the  toes  to  the  knee,  in  order  to  pre- 
vent the  swelling  which  is  apt  to  arise. 

The  objection  to  the  methods  I  have  described  in  the  foregoing 
paragraph  is  that  they  have  a  tendency  to  tilt  the  upper  frag- 
ment forward,  and  to  throw  it  out  of  its  proper  place — so 
difficult  is  it  to  act  upon  a  small  and  very  moveable  piece  of  bone. 
M.  Malgaigne  has  endeavoured  to  overcome  this  difficulty  by  a 
direct  method  of  treatment.  With  this  view  he  has  devised  the 
hooks  which  bear  his  name  (Fig.  72).     These  hooks  are  fixed  into 

Fig.  72. 


Malgaigne's  hooks. 

the  tendons  at  the  upper  and  lower  edge  of  the  patella,  so  as  to 
obtain  a  firm  hold  of  the  margins  of  the  bone,  and  then  drawn 
together  by  means  of  a  screw,  which  is  worked  with  a  key.  The 
pain  of  applying  the  hooks  is  trifling,  and  most  patients  bear 
them  without  discomfort ;  but  it  should  be  remembered  that 
considerable  inflammation  of  the  joint  has  taken  place  in  some 
cases  in  which  they  have  been  used,  and  for  this  reason  they  are 
not  regarded  with  much  favour  by  English  surgeons. 

Whatever  method  of  treatment  is  adopted,  it  must  be  continued 
for  about  six  weeks,  and  then  the  patient  may  be  allowed  to  get 
up  and  move  about  upon  crutches,  wearing  an  elastic  knee-cap, 
or  having  a  light  splint  applied  to  the  back  of  the  joint. 

Erichsen  speaks  highly  of  the  use  of  the  starched  bandage,  and 
says  that  the  patient  can  walk  about  during  the  whole  of  the 
treatment.  "  The  action  of  the  bandage,^'  he  adds,  "  is  much 
increased  by  drawing  down  and  fixing  the  upper  fragment  by  two 
broad  strips  of  plaster  firmly  applied  above  it.  A  back-splint  of 
pasteboard  is  required  to  fix  the  knee,  and  a  good  pad  of  lint 
with  a  figure-of-8  bandage  should  be  applied  above  and  below  the 
fracture  to  keep  it  in  position."  Some  surgeons  have  employed 
plaster  of  Paris  bandages  in  the  same  manner. 

In   this  accident,  as   well  as  in  many    others,  it   is  always 

M  2 


164  DISEASES  OF  TISSUES   AND   OEGANS. 

desirable  to  warn  the  patient  that  some  degree  of  lameness  is 
almost  certain  to  remain  as  a  result  of  the  injury. 

FRACTURES  OF  THE  IiEG. 

When  both  bones  are  broken,  the  fracture  is  easily  detected  by 
the  loss  of  power,  shortening,  mobility  and  crepitus ;  when  only 
one  has  suffered,  especially  if  that  one  be  the  fibula,  the  diagnosis 
is  more  difficult.  The  commonest  seat  of  fracture  is  at  the  junc- 
tion of  the  middle  and  lower  third  of  the  leg.  The  fracture  may 
be  either  transverse  or  oblique.  If  oblique,  the  fissure  runs  from 
above  downwards  and  backwards.  The  lower  fragment  over- 
rides the  upper,  in  consequence  of  the  action  of  the  muscles  of  the 
calf,  and  is  very  apt  to  protrude  through  the  skin. 

Treatment. — In  a  case  of  simple  fracture  of  both  bones,  if  there 
is  but  vei'y  little  swelling  or  displacement,  it  sometimes  suffices 
to  confine  the  patient  to  bed  for  a  few  days  with  his  leg  laid 
between  sand-bags ;  and  then  the  leg  may  be  encased  in  a  starch 
bandage.  This  plan  has  the  advantage  of  allowing  the  patient  to 
move  about  on  crutches  while  union  is  taking  place ;  but  the  sur- 
geon should  be  careful  to  examine  the  limb  from  time  to  time, 
to  see  that  the  bones  are  in  their  proper  position.  In  the  great 
majority  of  instances,  however,  there  is  so  much  displacement,  or 
mobility,  that  the  patient  must  be  confined  to  bed  for  a  longer 
period,  and  the  leg  fixed  by  some  kind  of  apparatus.  The  means 
which  have  been  devised  for  this  purpose  are  numerous;  but  here, 
as  elsewhere,  the  simpler  and  less  complicated  the  splint  the  more 
generally  useful  will  it  be  found. 

In  all  ordinary  cases  of  simple  fracture  of  both  bones,  the  best 
plan  of  treatment  is  to  apply  two  side-splints  with  foot  pieces,  the 
splints  being  well  padded,  and  secured  above  and  below  the  seat  of 
fracture  by  broad  strips  of  plaster,  or  by  a  few  turns  of  a  roller. 
Some  surgeons  are  of  opinion  that  the  outer  splint  only  should 
have  a  foot  piece,  the  inner  one  being  cut  off  at  the  ankle. 
But  there  seems  no  sufficient  reason  for  this,  and  it  is  more 
convenient  to  have  both  splints  of  the  same  shape,  so  that 
they  may  be  available  for  either  leg.  After  the  side-splints  have 
been  applied,  the  limb  may  either  be  simply  laid  on  the  bed — 
placed,  if  need  be,  between  a  couple  of  sand-bags— or  it  may  be 
supported  in  a  "  Salter's  Swing"  (see  Fig.  80) — or  suspended  under 
a  common  cradle  by  a  few  hoops  of  bandage.  Such  a  cradle 
may  easily  be  made  of  light  iron  rods  bent  so  as  to  form  a  series 
of  arches  connected  by  narrow  bars  of  wood  (Fig.  VS).  To 
keep  the  patient  from  hurting  his  leg  during  sleep,  the  cradle 
should  be  padded  with  cotton-wool  or  covered  with  a  roller. 
This  method  of  swinging  the  leg  not  only  gives  comfort  to  the 


FRACTURES   OF  THE  LEG. 


165 


patient,  but  also  tends  to  prevent  the  injury  which  might  arise 
from  involiTntary  starting  of  the  limb. 

Fig.  73. 


Leg  placed  on  a  back-splint,  and  suspended  under  a  cradle. 
Another  excellent  plan  of  treating  simple  fractures  of  the  leg, 
is  to  use  a  straight  iron  back-splint,  about  four  or  five  inches  broad, 
and  bent  upwards  at  its  lower  end  so  as  to  form  a  foot-piece  (such 
as  is  seen  in  Fig.  73).  The  material  of  which  the  splint  is  made 
should  be  thin  and  pliable,  so  as  to  allow  the  surgeon  to  adapt  it 
in  some  degree  to  the  shape  of  the  foot  and  leg.  It  should  be 
thoroughly  padded,  especially  above  and  around  the  heel,  so  that 
the  weight  of  the  foot  may  be  difi'used  over  the  ankle  and  leg, 
and  not  fall  entirely  upon  the  heel ;  for  the  skin  in  this  situation, 
like  the  skin  over  all  other  bony  prominences,  is  excessively  prone 
to  become  inflamed,  and  to  ulcerate,  under  continued  pressure.  If 
the  simple  back- splint  is  not  found  sufficient  to  keep  the  leg  in 
position,  a  straight  wooden  splint  may  be  added  on  one  or  both 
sides  to  give  lateral  support.  In  putting  up  a  fracture  of  the 
leg  it  is  well  to  leave  the  crest  of  the  tibia  as  far  as  possible 
uncovered,  so  that  the  surgeon  may  run  his  finger  along 
it  from  time  to  time,  and  ascertain  the  position  of  the 
fragments. 

If  the  line  of  fracture  through  the  tibia  is  oblique,  as  it  fre- 
quently is,  and  if  there  is  danger  of  the  lower  fragment  piercing 
the  skin,  it  is  desirable  to  relax  the  muscles  so  as  to  prevent  them 
from  acting  upon  the  bones,  and  converting  a  simple  fracture  into 
a  compound  one.  In  order  to  do  this  the  leg  may  be  laid  on  its 
outer  side  upon  a  broad  side-splint,  the  leg  and  the  thigh  being 
both  flexed.  But,  as  this  position  is  apt  to  become  irksome,  it  is 
more  usual  to  carry  out  the  same  indications  by  putting  up  the 
fracture  with  side-splints,  or  with  a  back-splint,  in  the  way 
already  described,  and  then  swinging  the  limb  in  such  a  manner 
as  to  flex  both  the  hip  and  the  knee. 

When  one  bone  alone  has  been  broken,  there  is  generally  but 
little  displacement,  the  sound  bone  helping  to  keep  the  broken 
one  in  its  proper  position.  In  such  a  case,  the  surgeon  may  have 
recourse  to  any   of  the  foregoing  methods,  being  guided  in  his 


166  DISEASES  OF  TISSUES  AND  OEaANS. 

choice  by  the  age  and  temperament  of  the  patient,  as  well  as  by 
the  details  of  the  injury.  For  example,  a  child,  or  a  patient  whose 
self-control  cannot  be  depended  upon,  must  be  confined  to  bed, 
and  means  used  to  insure  the  perfect  repose  of  the  limb ;  but  in 
other  instances  the  fracture  may,  after  a  day  or  two,  be  put  up 
with  a  starch  bandage.  When  the  fibula  alone  is  broken,  it  will 
sometimes  suffice  to  apply  strips  of  plaster  and  a  bandage  round 
the  leg  in  the  way  described  in  speaking  of  sprained  ankle  (see 
p.  104), 

Compound  fractures  of  the  leg  are  far  from  uncommon.  When 
the  wound  is  slight,  a  pad  of  lint  should  be  applied,  upon  which  the 
blood  will  coagulate,  and  thus  seal  the  wound ;  or  the  pad  may 
be  saturated  with  collodion  or  Friar's  balsam.  The  limb  may 
then  be  put  up  with  side-splints,  or  with  a  back-splint.  If  a 
point  of  bone  protrudes,  and  cannot  easily  be  reduced,  it  should 
be  removed  with  the  saw  or  bone-pliers.  If  the  wound  is  of 
larger  size,  and  the  soft  tissues  are  much  injured,  there  will 
probably  be  more  or  less  suppuration.  It  is  then  well  to  have 
recourse  to  a  M'Intyre's  splint  (Fig.   74) — i.e.,  a  concave  iron 

Fisr.  74. 


M'Intyre's  splint. 


splint,  with  a  thigh-piece  and  a  foot-piece,  and  a  joint  at  the 
knee,  regulated  by  a  screw,  so  that  it  can  be  fixed  at  any  angle, 
and  the  whole  leg  kept  perfectly  at  rest.  Whether  the  wound 
is  great  or  small,  or  whatever  may  be  the  kind  of  splint 
selected,  care  should  be  taken  to  leave  the  seat  of  injury  un- 
covered, so  as  to  allow  the  surgeon  to  examine,  and  treat  it, 
without  disturbing  the  position  of  the  limb.  In  putting  up  such 
a  fracture  it  is  a  good  practical  rule  to  keep  the  ball  of  the  great 
toe  in  a  line  with  the  inner  edge  of  the  patella  and  the  ante- 
rior superior  spine  of  the  ilium.  To  facilitate  this,  it  is  well  to 
have  at  hand  one  or  two  small  soft  pads,  which  may  be  used 
to  make  pressure  upon  particular  points,  in  order  to  bring  the 
broken  fragments  into  their  proper  line. 

In  treating  these  fractures,  the  surgeon  will  find  that  he  must 
vary  his  appliances  according  to  the  details  of  each  particular 
case.  Among  fractures  which  present  much  the  same  appear- 
ances, and  which  seem  to  belong  to  the  same  class,  one  case  will 
do  well  between  side-splints;  another  will  require  a  back-splint, 


FRACTURES  ABOUT  THE  ANKLE  JOINT.        167 

with  or  without  lateral  support ;  while  a  third  will  have  to  be 
laid  upon  a  M'Intyre's  splint  before  it  can  be  brought  into  a 
satisfactory  position. 

If  the  fracture  is  not  merely  compound,  but  the  whole  thick- 
ness of  the  limb  is  crushed  and  disorganized,  immediate  ampu- 
tation will  be  necessary. 

Compound  fractures  of  the  leg  are  often  associated  with 
troublesome  haemorrhage.  If  the  injury  is  in  the  middle  or 
upper  third  of  the  leg,  amputation  will  almost  certainly  be 
inevitable ;  if  it  is  in  the  lower  third,  it  may  be  possible  to  secure 
the  bleeding  vessels. 

FHACTURES  AlELOVT  THE  ANILJmJI  TOIITT. 

When  the  foot  is  violently  twisted  outwards,  the  fibula  is  apt 
to  give  way  about  two  or  three  inches  from  its  lower  end,  and 
such  fractures  are  frequently  attended  with  more  or  less  injury  to 
the  ankle  joint. 

The  diagnosis  is  not  difl&cult,  inasmuch  as  the  seat  of  fracture 
can  be  felt. 

In  the  simplest  cases  of  this  class  the  fibula  alone  is  broken, 
whilst  the  internal  lateral  ligament  of  the  ankle  joint  is  stretched 
or  lacerated.  When  this  is  the  whole  amount  of  the  injury,  there 
is  generally  little  or  no  displacement  of  the  foot,  and  the  only 
symptoms,  besides  the  fracture,  are  swelling  and  extravasation  of 
blood  about  the  ankle.  Here  simple  means  will  suflSce  for  a  cure. 
The  leg  should  be  laid  upon  a  pillow  for  a  few  days,  and  then  the 
fracture  can  be  put  up  with  strapping  and  a  bandage,  or  with  a 
starch  bandage.  Indeed,  in  some  cases,  if  the  patient's  time 
is  valuable,  the  leg  may  be  strapped  and  bandaged  at  once  (see 
p.  104). 

If  the  swelling  is  considerable,  it  is  well  to  treat  the  injured 
part  with  cold  lotions  (F.  21,  23),  or  with  fomentations ;  and  if 
these  are  retained  by  a  many-tailed  bandage,  a  little  gentle 
pressure  may  be  exerted  at  the  same  time  (see  Fig.  186). 

But  if  the  case  is  more  severe  than  this — if,  in  addition  to  the 
fracture  of  the  fibula  and  the  laceration  of  the  internal  lateral 
ligament,  the  internal  malleolus  is  snapped  off  as  well — then  it 
will  be  necessary  to  confine  the  patient  to  bed,  and  to  keep  his 
leg  at  rest  by  some  kind  of  apparatus.  The  first  step  in  the 
treatment  should  be  the  same  as  in  the  simpler  cases — the  leg 
should  be  laid  upon  a  pillow,  and  local  measures  used  to  subdue 
the  acute  symptoms.  After  this  has  been  effected,  the  leg 
should  either  be  simply  laid  between  sand-bags — the  sand-bags 
and  the  limb  being  encircled  at  intervals  by  loops  of  bandage, 
or  broad-tape,  so   as  to   keep  the  whole  in  position — or  else  it 


168 


DISEASES  OF  TISSUES  AND  OEGANS. 


may  be  fixed  between  a  couple  of  side-splints  with  foot-pieces, 
the  splints  being  secured  by  a  few  turns  of  a  roller  above  and 
below  the  fracture,  or  by  bands  of  webbing  and  buckles. 


Fig.  75. 


When  the  fibula  is  broken  and  the  internal 
lateral  ligament  ruptured,  the  foot  not  unfre- 
quently  suffers  a  partial  dislocation  outwards 
in  the  manner  described  by  Mr.  Percivall  Pott. 
This  is  clearly  shown  in  Fig.  75,  which  is 
reduced  from  the  original  illustration  in  Pott's 
"  Remarks  on  Fractures  and  Dislocations,"  1768. 
The  same  thing  may  happen  when,  in 
addition  to  the  fracture  of  the  fibula,  the 
internal  malleolus  is  splintered  ofi".  The  toes 
point  outwards,  and  the  external  border  of  the 
foot  is  turned  slightly  upwards.  As  this  dis- 
placement is  due  in  part  to  the  action  of  the 
muscles  which  pass  under  the  outer  malleolus, 
our  object  must  be  to  relax  them.  With  this 
view  the  knee  and  the  ankle  should  be  mode- 
rately bent,  and  then  the  leg  may  either  be  laid 
upon  its  outer  side  on  a  broad  side-splint,  or  fixed 
between  two  side-splints  with  foot-pieces,  care 
being  taken  to  apply  the  roller  in  such  a  way 
that  the  outer  splint  shall  press  the  foot  in- 
wards towards  the  median  line. 

It  is  in  cases  of  this  kind  that  tbe  short,  straight  splint,  known 
as  Dupujtren's,  is  sometimes  used.  Tbe  accompanying  illustra- 
tion ( Fig.  76)  shows  the  form  in  which  it  was  originally  employed 

Fig-.  76. 


Pott's  fracture. 


Dupuytren's  splint  applied. 

by  the  eminent  surgeon  whose  name  it  bears,  and  the  way  in 
which  he  was  in  the  habit  of  applying  it.  It  is  an  ordinary 
straight  wooden  splint  about  three  inches  broad,  and  long  enough 
to  extend  from  the  knee  to  a  short  distance  below  the  sole  of  the 
foot.  It  should  be  well  padded,  so  as  to  adapt  itself  to  the  inside 
of  the  leg,  the  pad  being  especially  thick  and  firm  where  it  fits 
into  tbe  hollow  above  the  internal  malleolus.  The  splint  is  ap- 
plied along  the  inner  side  of  the  leg,  and  secured  at  its  upper 
end  by  a  few  turns  of  a  roller.     The  foot  is  then  bent  over  the 


FRACTURES  ABOUT  THE  ANKLE  JOINT.        169 

thick  portion  of  the  pad,  which  serves  as  a  fulcrum,  so  as  to  press 

outwards  the  upper  end  of  the  lower  fragment,  and  retained  in 

this  position  by  broad  strips  of  plaster,  or  by  a  bandage.     The 

limb,  with  the  splint  affixed,  may  be  semiflexed  upon  its  outer 

side  on  a  pillow,  or  upon  its  inner  side  as  in  the  illustration.     In 

modern  practice,  however,  a  modification  of  Dupuy  tren's  apparatus 

is   generally   preferred. 

It   consists  of    a  short  Fig.  77. 

straight   splint   pierced 

with  holes  near  its  upper 

end,  and  furnished  with 


deep  notches  at  its  lower         Modem  form  of  Dupuytren's  splint. 
— in    fact,    it    is    like 

Liston's  long  splint  on  a  smaller  scale  (Fig.  77).  It  should  be  well 
padded,  especially  above  the  internal  malleolus,  and  then  applied 
on  the  inner  side  of  the  leg,  secured  at  its  upper  end  by  a  few 
turns  of  a  roller  and  below  by  a  figure-of-8  bandage  passing 
through  the  notches,  and  embracing  the  instep  and  heel  alter- 
nately. When  the  fracture  has  been  put  up  in  this  way,  the  limb 
may  be  laid  on  its  back,  or  suspended  in  a  "  Salter's  swing" 
(see  Fig.  80). 

In  treating  these  cases  of  fracture  of  the  fibula  with  injury 
about  the  ankle  joint,  the  splints  ought  not  to  be  used  for  more  than 
a  month  or-  five  weeks  for  fear  of  ankylosis ;  and  at  the  end  of 
that  time  the  surgeon  should  begin  to  make  passive  movements, 
so  as  to  secure  the  mobility  of  the  joint. 

When  both  bones  of  the  leg  are  broken  near  the  ankle  joint, 
the  injury  is  almost  always  the  result  of  direct  violence,  and  the 
fracture  is  frequently  compound  or  comminuted.  In  such  a  case 
the  foot  may  be  displaced  in  various  directions,  and  the  toes 
pointed  either  inwards  or  outwards.  No  very  precise  rules  can 
be  laid  down  for  the  treatment  of  such  injuries.  Each  case  must 
be  dealt  with  according  to  the  peculiarities  which  it  presents. 
Sometimes  the  leg  may  be  simply  laid  upon  a  pillow,  or  upon  a 
broad  side-splint ;  sometimes  a  short  straight  splint,  placed 
either  upon  the  inner  or  outer  side  of  the  limb,  may  be  the  best 
means  of  overcoming  the  displacement ;  sometimes  a  pair  of 
ordinary  side-splints  may  be  the  most  efficient  mode  of  treatment ; 
sometimes  a  common  back-splint  with  a  foot-piece,  or  a  M'ln- 
tyre's  splint,  will  bring  the  leg  into  the  best  position ;  and 
sometimes  the  surgeon  will  have  to  cut  down  a  wooden  splint, 
and  shape  it  so  as  to  meet  the  special  requirements  of  the  case. 


170  DISEASES   OF  TISSUES  AND  ORGANS. 


FBACTURES  OF  THE   TAKSAIi  AITB  SS&TA- 
TABSAIi  BOIO-ES. 

These  fractures  are  usually  the  result  of  great  aud  direct 
violence.  They  are  not  unfrequently  compound,  or  complicated 
by  dislocations,  and  there  is  always  much  injury  to  the  soft 
parts. 

Treatment. — Here,  as  in  the  case  of  the  severe  fractures  about 
the  lower  portion  of  the  leg,  it  is  impossible  to  lay  down  any 
precise  rules  for  the  guidance  of  the  surgeon.  He  must  study 
the  particulars  of  the  injury,  and  then  select  the  most  suitable  of 
the  methods  enumerated  in  the  preceding  paragraphs.  Local 
applications  will  have  to  be  used  to  subdue  the  inflammation.  It 
often  happens  that  a  paste-board  or  gutta-percha  splint  moulded  to 
the  part  will  be  found  more  eflScient,  and  more  comfortable  than 
any  other  apparatus.  Such  a  splint  may  be  so  shaped  as  to  give 
support  to  the  sound  parts,  while  it  permits  the  surgeon  to  dress 
the  wounds,  and  allows  a  free  escape  for  the  discharge. 

When  the  calcaneum  is  broken,  a  gutta-percha  splint  should  be 
moulded  upon  the  heel,  and  the  leg  flexed  so  as  to  relax  the 
muscles.  In  the  same  way,  when  the  tendo  Acbillis  is  ruptured, 
the  leg  should  be  bent  at  the  knee,  and  retained  in  that  posi- 
tion by  a  cord,  connected  at  one  end  v/ith  the  heel  of  the  patient's 
slipper,  and  at  the  other  with  a  bandage  passing  round  the  thigh. 
After  either  of  these  injuries  the  patient  should  wear  a  high- 
heeled  shoe  for  some  time,  when  he  begins  to  walk  about. 

In  the  severer  injuries  about  the  ankle  and  foot,  more  particu- 
larly if  the  fracture  is  complicated  with  a  dislocation,  it  may  be 
necessary  to  remove  some  of  the  bones.  The  astragalus  has 
frequently  been  removed  in  this  manner,  and  the  cases  have 
turned  out  remarkably  well.  If  the  patient  is  old  or  sickly,  so 
that  he  cannot  endure  the  strain  of  a  prolonged  or  painful  illness, 
amputation  maj"^  be  the  only  resource. 

Crutches. — When  a  patient  begins  to  move  about  after  any 
severe  accident  or  operation  involving  the  lower  extremities,  he 
has  generally  to  support  himself  upon  crutches  until  he  recovers 
the  use  of  his  limb.  The  crutches  should  be  just  long  enough  to 
enable  him  to  raise  the  injured  leg  off  the  ground,  while  he  stands 
firmly  upon  the  other.  The  cross-bar  should  be  well  padded,  so 
as  to  form  a  cushion  upon  which  he  may  bear  his  weight.  If 
this  is  not  done,  the  pressure  upon  the  axillary  nerves  may  be 
such  as  to  lead  to  a  partial  paralysis  of  the  arm.  In  hospital 
practice  it  is  always  well  to  wrap  a  piece  of  leather  or  cloth  under 


DISEASES  OF  JOINTS. 


171 


the  lower  end  of  the  crutch  to  prevent  it  from  slipping.  This  is 
necessary  because  patients  are  rather  awkward  when  they  begin 
to  use  crutches,  and  if  the  floor  of  the  ward  is  waxed,  or  if  it 
has  been  recently  washed,  they  are  very  apt  to  fall. 

The  best  crutches  that  we  can  recomnnend  in  private  practice 
are  those  in  which  the  shaft  and  the  handle  are  made  out  of  a 
single  piece  of  wood.  Sometimes  a  spring  is  put  in  the  upper 
part  of  the  shaft,  so  as  to  give  elasticity  to  the  cross-bar.  They 
should  be  tipped  with  little  leather  shoes  to  keep  them  from 
slipping. 

If  the  state  of  the  injured  limb  is  such  that  the  patient  ought 
not  to  use  it  at  all,  it  is  a  good  plan  to  support  it  with  a  bandage 
passed  under  the  foot,  the  ends  being  brought  up  evenly  in  front, 
and  tied  behind  the  neck.  In  this  way  a  sort  of  sling  is  made 
which  assists  the  patient  in  keeping  his  foot  oif  the  ground. 

DISEASES  or  JOIKTTS. 

Acute  Synovitis  may  arise  from  external  injury,  but  more  often 
it  is  caused  by  cold  or  wet.  It  is  often  associated  with  a  gouty, 
rheumatic,  or  syphilitic  habit,  and  it  usually  attacks  those  joints 
which  are  most  exposed — e.g.^  the  ankle  or  knee. 

During  the  early  stage  the  synovial  membrane  is  red  and  vas- 
cular. If  the  disease  continues,  it  gradually  becomes  thickened 
and  villous.  The  quantity  of  fluid  secreted  is  greatly  increased. 
At  first  it  is  clear  and  serous.  Subsequently  it  becomes  turbid 
and  contains  flakes  of  lymph,  or  is  mixed  with  blood.  Ultimately 
it  may  become  purulent,  and  when  this  happens  the  cartilages  are 
very  apt  to  ulcerate. 

Symptoms. — Heat,  pain  gradually  increasing  in  intensity,  and 
great  tenderness,  early  and  rapid  swelling,  which  is  very  characteris- 
tic in  its  shape,  inasmuch  as  it  shows  itself  between  the  bony  pro- 
minences,    wherever 

the    synovial    cavity  Fig.  78. 

can  find  room  to  ex- 
pand. Thus,  in  the 
knee,  where  it  is  so 
often  seen,  it  assumes 
something  of  a  horse- 
shoe form  round  the 
sides  of  the  patella, 
between  that  bone 
and  the  condyles  of 
the  femur.  In  the 
hip  it  bulges  in 
front;  in  the  shoulder  Synovitis  of  the  ankle-joint. 


172  DISEASES  OF  TISSUES  AND  OEGANS. 

it  forms  a  smooth  rounded  swelling  beneath  the  deltoid;  in  the 
elbow  it  becomes  prominent  on  each  side  of  the  olecranon ;  and 
in  the  ankle  at  each  side  of  the  extensor  tendons  (Fig.  78). 
There  is  fluctuation.  The  joint  is  flexed  and  powerless,  and 
there  is  more  or  less  constitutional  disturbance. 

Treatment. — The  joint  should  have  perfect  rest  upon  a  splint. 
Fomentations  or  poultices,  plain  or  medicated,  should  be  con- 
tinuously applied.  Sometimes  cold  lotions  give  most  relief.  If 
the  patient  is  plethoric,  and  the  inflammation  runs  high,  blood 
should  be  freely  drawn  from  the  joint  by  leeches.  If  the  hip 
or  the  knee  is  affected,  extending  the  limb  by  means  of  a 
weight  gives  great  relief  in  some  cases,  even  in  the  acute  stage 
(see  Fig.  69). 

At  the  outset  of  treatment  a  purgative  should  be  prescribed, 
and  this  should  be  followed  by  salines.  If  the  attack  is  associated 
with  a  gouty,  rheumatic,  or  syphilitic  state  of  constitution, 
colchicum,  the  alkalies,  and  the  iodide  of  potassium  should 
respectively  form  part  of  the  treatment.     (F.  56,  60.) 

If  there  is  reason  to  suspect,  from  the  occurrence  of  rigors, 
that  suppuration  has  taken  place,  a  grooved  knife  or  needle 
should  be  introduced  into  the  joint  to  ascertain  the  fact,  and  then 
an  incision — and  if  need  be,  a  counter -incision — should  be  made, 
and  poultices  applied. 

In  traumatic  cases  the  continuous  application  of  an  ice-bag, 
or  a  strict  adhesion  to  Lister's  antiseptic  method  of  treatment, 
will  be  the  most  likely  means  of  securing  a  favourable  result. 

When  the  acute  symptoms  have  been  subdued,  friction  with 
unguents  or  liniments,  and  a  bandage,  will  help  to  remove  the  swell- 
ing and  stiffness,  and  to  restore  the  part  to  a  natural  condition. 

As  the  knee  joint  is  very  often  attacked  with  synovitis,  we  may 
take  this  opportunity  of  mentioning  that  a  convenient  bandage 
for  retaining  poultices  or  dressings  upon  the  knee  or  in  the  popli- 
teal space,  as  well  as  in  other  situations,  may  be  made  by  taking 
a  piece  of  calico  about  a  yard  and  a  half  long  and  a  foot  wide, 
and  tearing  it  up  the  middle  from  each  end  to  within  six  inches 
of  the  centre.  It  is  applied  in  the  following  manner : — The 
surgeon  lays  the  central  portion  either  over  or  under  the  knee, 
as  the  case  may  require,  and  brings  the  two  upper  tails  round 
the  limb,  and  crossing  them,  carries  them  back  to  the  point  from 
which  he  started,  and  ties  them  there.  The  two  lower  tails  are 
then  fastened  in  a  similar  manner. 


CHRONIC  SYNOVITIS.  173 


CHRONIC  SVSJOVZTZS 

is  often  the  result  of  the  foregoing,  though  sjoraetimes  the  inflam- 
mation has  from  the  first  a  subacute  or  chronic  character. 

There  is  less  pain  and  tenderness  than  in  the  acute  form,  but 
tlie  joint  is  swollen,  and  the  synovial  membrane  thickened  and 
pulpy.  In  many  instances  when  pressure  is  made  upon  it,  a  fine 
crackling  can  be  felt — the  result  of  efi'usion  into  the  meshes  of  the 
areolar  tissue.  When  the  accumulation  of  fluid  in  the  joint  is 
great,  while  the  inflammatory  symptoms  are  almost,  or  quite, 
absent,  the  disease  is  termed  hydrops  articuli  or  hydrarthrosis. 

Treatment. — In  chronic,  as  in  acute  synovitis,  there  is  usually 
some  constitutional  taint  which  must  be  met  by  its  appropriate 
remedies.  With  regard  to  local  treatment  it  is  of  the  utmost 
importance  to  give  the  pai't  perfect  rest  on  a  splint,  and  to  make 
regulated  pressure  by  means  of  a  bandage.  In  addition  to  this 
the  surgeon  will  find  it  necessary  to  try  various  means,  one 
after  another.  The  joint  should  be  rubbed  with  stimulating 
ointments  or  embrocations,  or  it  should  be  painted  with  lin.  iodi, 
or  blistered,  or  strapped,  with  or  without  the  application  of 
"  Scott's  dressing."  This  dressing  takes  its  name  from  "  Scott, 
of  Bromley."  It  is  very  useful  in  many  of  the  chronic  diseases 
of  joints,  and  is  applied  in  the  following  manner  : — The  joint  is 
first  sponged  with  camphorated  spirit,  and  then  evenly  covered 
with  strips  of  lint  spread  with  strong  mercurial  ointment  mixed 
with  camphor  (ung,  hyd.  co.).  The  strips  of  lint  should  be  about 
two  inches  broad,  and  they  ought  to  be  applied  in  the  same  way  as 
a  many-tailed  bandage  (see  Fig.  186).  The  ends  ought  to  overlap 
one  another  a  little,  but  care  must  be  taken  that  this  overlapping 
does  not  happen  to  fall  upon  any  bony  prominence,  such  as  the 
patella.  After  the  joint  has  been  covered  with  the  strips  of  lint 
it  should  be  encircled  in  the  same  way  with  strips  of  leather 
plaster,  so  as  to  form  a  firm,  dry  case.  Over  this  a  bandage 
may  be  applied,  and  by  this  means  a  degree  of  pressure  may  be 
employed,  if  it  seems  desirable.  The  dressing  may  generally  be 
allowed  to  remain  on  for  a  week  or  ten  days  before  it  requires  to 
be  renewed. 

Bandage  for  the  Tcnee. — It  often  happens  that  the  surgeon  has 
to  bandage  the  knee  either  to  give  it  support  after  fracture,  or  to 
exercise  gentle  pressure  upon  it,  as  in  some  of  the  diseases  to  which 
the  joint  is  liable.  The  bandage  may  be  most  conveniently 
applied  in  the  form  of  a  figure-of-8  (Fig.  79).  The  end  of  the 
roller  should  be  laid  upon  the  outer  side  of  the  head  of  the  tibia, 
carried  round  the  back  of  the  leg  from  without  inwards,  and  some- 


174  DISEASES  OF  TISSUES  AND  OEGANS. 

what  obliquely  from  below  upwards.  Then  it  should  be  brought 
round  the  inside  of  the  leg,  and  carried  across  the  front  of  the  joint, 
still  tending  obliquely  from  below  upwards.  Then  round  the 
back  of  the  thigh  in  a  transverse  direction  to  its  inner  side,  from 
whence  it  is  conducted  obliquely  across  the  front  of  the  joint 
from  above  downwards  to  the  point  at  which  it  commenced.  These 
figures  may  be  repeated  as  often  as  they  are  necessary ;  each  one 
rising  a  little  higher  up  the  limb  than  the  preceding  one,  and  care 

Eig.  79. 


Bandage  for  the  knee. 

being  taken  that  the  corresponding  folds  are  equidistant  from  one 
another.  The  turns  ought  not  to  cross  one  another  directly  over 
the  patella,  but  a  little  to  its  outer  side.  It  will  be  observed 
that  the  appearance  of  this  bandage,  when  properly  applied,  is 
very  much  the  same  as  that  produced  by  "reverses." 

I.OOSB  CARTZX.AGES  IN*  JOIM'TS. 

Loose  cartilages  are  most  frequently  met  with  in  the  knee 
joint.  They  seem  to  commence  in  a  thickening  of  the  fringes  of 
the  synovial  membrane,  the  result  of  chronic  synovitis,  and  are 
often  associated  with  rheumatism.  They  are  usually  composed 
of  condensed  fibrous  tissue.  It  is  seldom  that  they  have  a  car- 
tilaginous structure.  They  can  be  felt,  and  moved.  Sometimes 
they  come  between  the  articular  surfaces  causing  great  pain,  and 
perhaps  making  the  patient  fall  suddenly  to  the  ground.  This 
pain  is  probably  caused,  as  Erichsen  says,  by  the  sudden  and 
forcible  stretching  of  the  ligaments  of  the  joint,  for  "the  sen- 
sibility of  the  ligaments  of  a  joint  is  of  that  peculiar  nature 
that  it  is  only  called  into  action  when  an  attempt  is  made  to 
stretch  them,  and   thus  forcibly  to  counteract  or  destroy  their 


ARTHEITIS.  175 

natural  use.  Ligaments  may  be  cut  without  any  suffering,  but 
they  cannot  be  stretched,  either  by  accident  or  disease,  without 
the  most  severe  pain." 

Treatment, — Sometimes  they  can  be  fixed  in  one  corner  of  the 
joint  by  an  elastic  knee-cap  or  bandage,  until  they  contract  adhe- 
sions. j\lr.  Hilton  recommends  that  the  joint  should  be  kept 
perfectly  at  rest,  and  counter-irritation  applied  over  the  loose 
cartilage  with  a  view  of  procuring  its  absorption.  In  this  way 
the  symptoms  to  which  they  give  rise  may  be  palliated.  If, 
however,  the  sufferings  of  the  patient  are  great,  and  if  milder 
measures  have  failed,  the  loose  cartilage  may  be  pushed  into  a 
corner  of  the  synovial  cavity,  and  removed  by  a  subcutaneous 
incision,  being  either  drawn  out,  or  left  in  the  areolar  tissue  till 
it  becomes  absorbed.  Under  an  antiseptic  spray  surgeons  have 
dealt  more  freely  with  the  joint,  laying  it  open  and  removing  the 
loose  cartilages  at  once.  But  this  operation,  simple  though  it 
sounds,  is  not  unattended  with  danger,  and  should  not  be  under- 
taken except  as  a  last  resource. 

ARTHRITIS. 

By  arthritis  is  meant  an  inflammatory  condition  of  a  joint 
affecting  more  or  less  all  the  structures  that  enter  into  its  com- 
position. 

It  may  be  either  acute  or  chronic.  It  may  begin  in  the  syno- 
vial membrane,  or  in  the  ligaments,  or  in  the  cartilage,  or  in  the 
bones,  and  spread  thence  to  the  adjacent  parts. 

It  generally  occurs  in  persons  who  are  of  an  unhealthy  con- 
stitution, or  who  are  out  of  condition  at  the  time.  It  is  often 
excited  by  twists,  blows,  or  wounds.  Sometimes  it  is  a  conse- 
quence of  pysemia,  or  puerperal  fever. 

Symptoms  of  acute  arthritis. — The  whole  tissues  of  the  joint 
are  somewhat  swollen.  The  enlargement  is  general :  it  does  not, 
as  in  synovitis,  show  itself,  chiefly  in  certain  situations.  The 
skin  is  hot,  and  pervaded  by  a  slight  blush.  The  tenderness  is 
such  that  the  patient  cannot  bear  the  part  to  be  touched.  The 
pain  is  exquisite,  and  aggravated  by  the  least  movement.  It  is 
commonly  referred  to  one  spot,  and  is  generally  worse  at  night. 
There  are  painful  startings  of  the  limb,  which  prevent  the  patient 
from  sleeping,  and  add  greatly  to  his  sufferings.  With  these 
local  symptoms  there  is  usually  a  high  degree  of  constitutional 
disturbance. 

The  disease  spreads  rapidly,  and  the  various  tissues  of  the  joint 
soon  become  affected.  The  cartilages  ulcerate,  the  synovial  mem- 
brane becomes  thickened  and  gelatinous,  the  ligaments  are 
softened  and  disorganized,  the  joint  becomes  unnaturally  move- 


176 


DISEASES   OF  TISSUES   AND  OEGANS. 


able,  and  the  articular  surfaces  grate  upon  one  another.  Sup- 
puration commonly  takes  place,  and,  if  the  joint  is  not  opened,  the 
matter  makes  its  way  to  the  surface  at  various  points. 

In  the  treatment  of  a  case  of  acute  arthritis,  the  patient  should 
be  kept  perfectly  at  rest ;  the  affected  limb  should  be  fixed  on  a 
sphnt,  or  be  laid  between  sand-bags.  If  it  is  the  knee  that 
is  diseased,  great  relief  will  be  given  by  extending  the  limb  by 
means  of  a  weight  hung  over  the  end  of  the  bed,  or  by  suspend- 
ing the  leg  in  a  "  Salter's  swing"  (Fig.  80).     The  joint  should 

Fis-.  80. 


Leg  suspended  in  Salter's  swing. 

be  freely  leeched,  and  constantly  fomented;  calomel  should  be 
given  in  combination  with  opium,  and  the  general  treatment  must 
be  strictly  antiphlogistic.  If  the  inflammation  subsides  without 
the  formation  of  matter,  and  falls  into  a  subacute  or  chronic 
stage,  counter-irritation  by  blisters  or  iodine  paint,  or  encasing 
the  part  with  strips  of  emp.  belladonnae,  or  emp.  ammoniaci  c. 
hydrargyro,  or  the  application  of  "  Scott's  dressing,"  will  be 
found  very  beneficial. 

If  suppuration  takes  place,  a  free  incision — and  perhaps  a 
counter-incision — must  be  made  into  the  joint,  and  poultices 
applied.  If  it  is  one  of  the  larger  joints  that  is  affected,  as  the 
hip  or  the  knee,  the  patient  will  be  in  great  danger  of  sinking 
from  exhaustion  or  hectic.  If  he  recovers,  it  will  probably  be 
with  a  stiff  joint.  The  limb  should  therefore  be  placed  at  the 
outset,  and  maintained  during  treatment,  in  such  a  position  as 
shall  be  most  useful  in  case  ankylosis  should  result. 

CHBON-ZC    RHEUMATIC   ARTHRITIS 

affects  small  and  large  joints  alike.  It  is  essentially  chronic  in 
its  character,  and  is  often  associated  with  gout.  It  is  usually 
preceded  by  a  low  and  depressed  state  of  the  general  health,  and 


CHRONIC   RHEUMATIC  ARTHRITIS. 


177 


seems  to  depend  almost  as  much  on  the  state  of  the  nervous 
system  as  on  the  condition  of  the  blood.  It  steals  on 
gradually  from  joint  to  joint,  often  commencing  in  joints 
that  have  previously  been  weak  or  injured.  There  is  dull, 
aching  pain,  at  first  slight  and  intermittent,  afterwards  severe 
and  constant,  with  occasional  subacute  exacerbations.  In  the 
early  stages  of  the  disease  the  movements  of  the  joint  are  only 
impeded  by  the  pain,  but  in  the  later  stages  they  are  limited  by 
the  changes  that  take  place  in  the 
articular  surfaces;  the  joints  "grow  out" 
(as  patients  say),  and  then  a  distinct 
grating  or  cracking  may  be  felt,  and 
sometimes  heard,  on  moving  the  joint. 

Where  there  is  pressure  the  cartilage 
becomes  gradually  worn  away,  and  the 
subjacent  surface  of  bone  grows  hard  as 
ivory  (eburnated).  In  other  situations, 
the  cartilage  becomes  irregularly  de- 
veloped, and  an  ossific  deposit  takes 
place  in  it  and  in  the  white  fibrous 
tissues.  Together  with  these  deposits 
the  cancellous  tissue  of  the  bone  some- 
times becomes  distended.  The  joint 
becomes  more  or  less  fixed,  and  the 
muscles  waste.  Fig.  81  represents  a 
section  of  the  tibia  of  a  man  who  was 
long  under  my  observation.  The  arti- 
cular extremities  of  the  bone  were  ex- 
panded, the  cartilages  absorbed,  the 
surfaces  of  the  joints  like  porcelain,  the 
ligaments  thickened,  and  portions  of  the 
muscles — especially  the  tibialis  anticus — 
ossified.  In  this  patient  many  joints 
were  similarly  affected. 

As  I  have  said,  the  disease  often  takes 
its  starting  point  from  an  injury ;  it  may 
be,  from  a  mere  bruise.  The  surgeon 
should  remember  this,  for  the  bruise  may 

be  followed,  particularly  at  the  hip-joint,  by  a  train  of  symptoms 
which  simulate  fracture,  and  unless  he  has  warned  his  patient, 
he  may  be  blamed. 

Treatment. — We  can  do  little  either  to  arrest  the  progress  of 
the  disease,  or  to  repair  the  damage  it  has  done.  Tonics  are 
essential :  for  example,  the  preparations  of  iron,  or  cod-liver  oil. 
Iodide  of  potassium,  the  alkalies,  and  guaiacum  should  be  tried. 

N 


Chronic  rheumatic 
arthritis. 


178  DISEASES   OF  TISSUES  AND  OEGANS. 

Friction  with  stimulating  liniments,  warm  clothing,  a  good  but 
regulated  diet,  and  attention  to  the  general  health,  are  points 
which  must  not  be  overlooked.  A  visit  to  the  springs  of  Buxton, 
Bath,  or  Aix-la-Chapelle  may  perhaps  be  beneficial.  The  seaside 
does  not  generally  suit  the  subjects  of  this  disease. 

XriiCERATIOU  OF  CARTIIiACE 

may  occur  as  the  result  of  synovitis,  or  it  may  depend  upon  disease 
of  the  subjacent  bone,  or  it  may  originate  in  the  cartilage  itself. 

Ulceration  beginning  in  the  cartilage  itself  is  a  rare  disease  ; 
but  as  a  consequence  of  synovitis,  or  scrofulous  inflammation  in 
the  cancellous  ends  of  the  bones,  it  is  common. 

The  treatment  resolves  itself  into  that  of  synovitis,  arthritis, 
or  scrofulous  disease  of  joints. 

SCROFVZiOUS  DISEASE  OF  JOZSTTS 

(white  swelling)  occurs  chiefly  before  the  age  of  puberty,  and  in 
those  who  are  of  a  strumous  habit  of  body.  Its  exciting  cause 
is  sometimes  very  slight — e.g.,  a  blow  or  a  sprain. 

The  disease  usually  begins  in  the  synovial  membrane. 
Sometimes,  however,  it  seems  to  have  its  origin  in  the 
cancellated  tissue  of  the  bone.  Wherevef  it  commences, 
the  morbid  action  soon  pervades  both  the  hard  and  the  soft 
tissues ;  the  ends  of  the  bones  become  enlarged,  the  can- 
celli  dilated  and  filled  with  fat  or  tubercular  matter,  the  synovial 
membrane  vascular  and  pulpy,  the  ligaments  soft  and  disorgan- 
ized, and  the  subcutaneous  tissues  swollen  and  thickened. 

When  the  disease  is  fully  established,  the  joint  has  a  very 
characteristic  appearance.  It  is  gradually  and  uniformly  enlarged, 
the  surface  is  pale,  with  blue  veins  traversing  it,  the  skin  is 
doughy  or  oedematous,  and  after  suppuration  has  taken  place, 
there  are  generally  the  marks  of  sinuses  in  various  situations. 

The  patient  lies  with  his  limb  semi-flexed.  He  has  not  much 
pain,  except  when  the  joint  is  moved.  The  muscles  of  the  affected 
part  waste  from  disuse,  and  there  is  gradually  a  total  loss  of 
power.  At  the  same  time  the  general  health  suffers,  there  are  the 
constitutional  marks  of  scrofula,  and  when  suppuration  takes 
place,  the  patient  is  very  apt  to  fall  into  a  hectic  state.  If  this 
happens,  he  will  be  in  imminent  peril  of  sinking  from  phthisis 
or  some  other  internal  development  of  the  tubercular  disease. 

Treatment. — The  joint  should  be  kept  perfectly  at  rest  by 
means  of  a  splint,  and  in  such  a  position  as  shall  make  the  limb 
most  useful  in  the  event  of  ankylosis. 

If  the  symptoms  are  but  slight,  the  patient  should  wear  an 
elastic  bandage,  or  a  light  splint  made  of  gutta-percha  or  sole 
leather ;  and  he  should  be  very  careful  that  the  joint  sustains  no 


ANKYLOSIS.  179 

injury.  Thus,  if  the  elbow  is  affected,  he  should  avoid  all  blows 
upon  it,  and  if  the  knee  is  the  part  threatened,  walking  over 
rough  ground,  dancing,  running,  and  everything  that  can  jar  or 
twist  the  joint  should  be  forbidden. 

If  the  inflammation  is  acute,  leeches  may  be  required.  But 
depletion  of  any  kind  should  be  used  with  caution,  for  we  are 
dealing  with  a  disease  which  is  the  result  of  debility.  If  there 
is  much  heat  and  pain,  cooling  lotions  or  fomentations  should  be 
constantly  applied ;  but  they  should  be  laid  aside  as  soon  as  the 
acute  symptoms  have  subsided.  Counter-irritation,  or  the 
application  of  blue  ointment  and  camphor  (Scott's  dressing),  with 
careful  bandaging  and  well-regulated  pressure,  will  be  of  use. 
But  what  is  likely  to  do  most  good  is  constitutional  treatment, 
combined  with  rest.  The  patient  should  have  plenty  of  sunlight 
and  fresh  air ;  if  possible,  he  should  go  to  the  sea-coast.  His 
diet  should  be  generous,  but  well-selected ;  and  he  should  take 
cod-liver  oil  or  steel,  or  other  tonic  medicines. 

If  matter  forms,  it  should  be  let  out  at  once,  and  a  poultice 
applied.  If  the  suppuration  is  profuse,  it  must  be  dealt  with  on 
general  principles,  the  wound  being  syringed  out,  and  dressed 
with  antiseptic  lotions.  At  the  same  time  everything  should  be 
done  to  ward  off  hectic  by  the  administration  of  quinine,  the 
mineral  acids,  and  similar  tonics  (F.  52,  65).  As  a  last  resource 
excision,  or  amputation,  may  have  to  be  performed. 

AM-KYXiOSIS 

means  the  union  which  not  unfrequently  takes  place  between  the 
articular  surfaces  of  bones.  It  is  always  the  result  of  inflamma- 
tion. Sometimes  it  is  membranous  ov  fibrous,  at  other  times  it  is 
osseous. 

Fibrous  or  membranous  ankylosis  occurs  in  those  cases  in 
which  the  inflammation  has  been  confined  to  the  synovial 
membrane  and  cartilage,  and  in  which  the  bone  has  not  been 
exposed.  The  opposed  surfaces  are  held  together  by  fibrous 
tissue,  or  by  adhesions  of  plastic  lymph. 

Osseous  ankylosis  takes  place,  when  the  deeper  tissues  have 
been  exposed,  and  the  two  bony  surfaces  are  able  to  coalesce,  and 
grow  together.  Fig.  82  afibrds  a  good  example  of  osseous 
ankylosis  at  the  knee-joint. 

Treatment. — When  a  joint  is  in  danger  of  becoming  stifi",  it 
should  always  be  placed  in  the  most  useful  position.  The  knee, 
for  example,  should  be  extended  almost,  though  not  quite,  to  the 
full ;  the  elbow  bent  to  something  less  than  a  right  angle. 

If  the  ankylosis  is  fibrous,  and  the  limb  is  in  good  position, 
passive  motion  should  be  made,  and  the  joint  bathed  with  cold 

N  2 


180 


DISEASES   OF  TISSUES  AND  ORGANS. 


Bony  ankylosis  at  the 
knee-joint. 


water,  or  rubbed  with  stimulating  embrocations,  in  the  hope  of 
exciting  healthy  action,  and  restoring  some  degree  of  movement. 
In  such  a  case  salt-water  douches  may  be 
very  useful.  But  if  the  limb  is  fixed  in 
a  bad  position,  the  patient  should  be 
anaesthetized,  and  force  applied  to  the 
joint,  so  as  to  bring  it  into  a  more 
useful  form ;  and  then,  if  the  surgeon 
thinks  fit,  passive  motion  may  be  made 
as  in  the  previous  case.  The  synovial 
membrane  having  been  destroyed  by 
the  inflammation,  there  is  little  or  no 
risk  of  doing  harm  by  these  forcible 
measures. 

In  dealing  with  diseases  or  injuries 
which  involve  joints,  either  directly  or 
indirectly,  the  surgeon  should  bear  in 
mind  the  readiness  with  which  mem- 
branous adhesions  are  formed,  and  en- 
deavour to  prevent  them  by  timely  move- 
ment. These  are  the  cases  which  furnish 
the  bone-setters  with  their  successes.  Dr. 
Wharton  Hood  has  shown  the  principle 
which  underlies  their  rough-and-ready  treatment,  and  has  enabled 
scientific  surgery  to  learn  a  lesson  from  quackery — Fas  est  et  ah 
hoste  doceri.  Dr.  Hood  has  pointed  out  that  when  there  is  no  active 
disease  in  a  joint,  except  such  as  is  kept  up  by  the  irritation  of  the 
membranous  bands — when  there  is  a  certain  amount  of  movement, 
checked  by  pain,  and  that  pain  referable  to  a  single  spot,  we  may 
assume  that  adhesions  are  the  source  of  the  patient's  trouble,  and 
endeavour  to  break  them  by  quick  decisive  movements  of  flexion 
and  extension.  Of  course,  in  applying  this  treatment,  great 
care  must  be  taken  in  arriving  at  a  diagnosis,  and  in  excluding 
all  possibility  of  active  disease  in  or  around  the  joint.  It  is  ap- 
plicable to  joints  crippled  by  injury,  by  inflammation,  by  strumous, 
gouty,  or  rheumatic  disease  ;  but  where  there  is  a  constitutional 
tendency  to  articular  affections,  as  in  the  case  of  strumous  or 
gouty  persons,  it  must  be  used  with  even  greater  caution  (Hood, 
"  On  Bone-setting,  so-called"). 

If  the  ankylosis  is  osseous,  nothing  short  of  an  operation  can 
alter  it.  We  must  either  be  content  with  the  limb  as  it  is,  or 
else  perform  a  subcutaneous  osteotomy,  an  excision  or  an  amputa- 
tion. 

Subcutaneous  osteotomy  is  an  operation  which  has  only  been 
practised  of  late  years,  and  which  owes  much  to  Mr.  W.  Adams. 


DISEASE  OF  THE  HIP-JOINT.  181 

The  details  of  the  operation  must  depend  upon  the  situation  in 
which  it  is  to  be  performed,  and  the  exact  relation  of  the  bone 
to  the  neighbouring  vessels,  nerves,  &c.  Speaking  generaDy,  a 
uarrow-bladed  knife  is  passed  down  to  the  point  where  the  sec- 
tion is  to  be  made.  This  is  withdrawn,  and  a  fine  saw,  or  small 
chisel,  is  introduced  along  its  track.  The  bone  is  then  sawn, 
or  cut,  through ;  the  superficial  wound  closed  with  plaster ;  the 
limb  brought  into  good  position,  and  fixed  on  a  suitable  splint. 
The  chisel  is  preferable  to  the  saw,  because  it  leaves  no  debris, 
and  does  less  injury  to  the  soft  tissues. 

DISEASE  OF  THE  HIP-JOZNT 

is  very  common,  very  important,  and  presents  some  peculiar 
features. 

It  is  a  truly  scrofulous  disease,  and  occurs  almost  always  before 
the  age  of  puberty.  In  children,  the  morbid  action  usually  begins 
in  the  bones,  but  it  may  originate  in  the  cartilages,  synovial 
membrane,  or  ligaments.  In  any  case,  the  course  and  history 
of  the  disease  is  much  the  same. 

It  is  often  excited  by  very  slight  accidents — e.g.,  a  fall  or  a 
twist.     Frequently  it  arises  without  any  assignable  cause. 

Symptoms. — The  earliest  of  these  are  trifling  and  intermit- 
tent pain,  perhaps  referred  to  the  knee ;  slight  lameness  when 
the  patient  is  tired ;  inability  to  stand  upon  the  affected  limb  ; 
some  puffiness  about  the  hip,  and  perhaps  also  about  the  knee ; 
the  buttock  is  flattened  from  disuse  of  the  glutei  muscles ;  the 
knee  of  the  affected  side  points  across  the  sound  one ;  the  foot 
is  inverted  :  th6  thigh  is  adducted,  slightly  flexed  on  the  pelvis, 
and  cannot  be  extended  without  giving  pain.  If  the  patient  is 
laid  flat  on  his  back,  the  thigh  rises ;  and  if  the  thigh  is  laid 
flat,  the  back  rises — that  is  to  say,  there  is  some  loss  of  move- 
ment at  the  hip-joint.  If  the  trochanter  is  struck,  or  if  the 
leg  is  jerked  upwards,  there  is  acute  pain  in  the  joint.  The 
limb  should  be  carefully  measured  and  compared  with  its  fellow. 
At  first,  it  is  sometimes  slightly  lengthened  from  effusion  into 
the  capsule;  subsequently,  it  is  apparently  considerably  lengthened 
by  the  obliquity  which  the  patient  habitually,  and  almost  invo- 
luntarily, gives  to  his  pelvis.  In  order  to  take  the  weight  of  his 
body  off  the  diseased  joint,  he  "stands  at  ease;"  he  bears  upon 
the  sound  limb,  throws  out  the  sound  hip,  and  lowers  the 
pelvis  on  the  affected  side.  In  the  later  stage  there  is  often 
shortening  from  absorption  or  dislocation.  The  joint  becomes 
uniformly  swollen,  the  tissues  thickened,  the  skin  distended, 
glazed,  and  doughy  to  the  touch.  If  suppuration  takes  place,  an 
indistinct  fluctuation  may  be  felt ;  abscesses  may  point  above  or 


182 


DISEASES  OF  TISSUES  AND  ORGANS. 


below  Poupart's  ligament,  or  in  the  neighbourhood  of  the  tro- 
chanter, or  in  the  gluteal  region  ;  and  sinuses  may  bo  left,  com- 
municating with  the  joint  in  various  directions.  After  a  longer 
or  shorter  time  dislocation  on  to  the  dorsum  ilii  will  probably 
take  place. 

These  are  the  general  features  of  a  case  of  coxalgia,  or  hip  disease. 
But  it  is  desirable  to  try  and  make  an  accurate  diagnosis  of  the 
exact  part  involved  in  the  morbid  action.  Thus,  when  the  soft 
tissues  are  chiefly  or  solely  affected,  the  disease  is  called  arthritic 
coxalgia  ;  when  the  acetabulum  and  pelvic  bones  are  involved, 
„.     J.O  we  s]^eak  of  acetabular 

coxalgia;  and  when 
the  femur  is  affected, 
it  is  distinguished  as 
femoral  coxalgia.  The 
prognosis,  and  the 
fitness  of  the  case  for 
operation,  are  affected 
by  the  exact  situation 
as  well  as  by  the 
extent  of  the  disease. 
Of  course,  the  various 
forms  of  the  disease 
are  often  associated 
in  the  same  patient. 
Fig.  83  represents  a 
case  in  which  the 
acetabulum  has  been 
destroyed,  and  per- 
forated in  several  places ;  and  in  which  the  head  of  the  femur 
is  also  extensively  necrosed. 

Treatment. — The  joint  should  have  perfect  rest  on  a  splint. 
If  the  case  is  in  an  early  stage,  the  limb  should  be  extended,  and 
fixed  by  means  of  a  long  splint.  In  young  children,  it  is  an 
excellent  plan  to  lay  a  sand  pillow  on  each  side  of  the  body, 
and  a  short  one  between  the  legs,  and  stretch  a  sheet  tightly 
over  them ;  or  a  weight,  to  be  gradually  increased,  may  be  affixed 
round  the  ankle,  and  hung  over  the  end  of  the  bed  (see  Fig.  69). 
Sayre,  of  New  York,  has  devised  a  useful  apparatus  whereby  the 
limb  may  be  kept  straight,  and  extension  made,  without  the 
necessity  of  confining  the  patient  to  bed. 

If  there  is  acute  inflammation  in  the  early  stage,  leeches  may 
be  required.  Counter-irritation  by  blisters,  issues,  setons,  &c.,  is 
extremely  useful  when  the  disease  threatens  to  become  chronic. 
If  an  abscess  forms,  it  should  be  opened  by  a  direct  incision  ;  in 


Acetabular  disease  of  the  hip- joint. 


DISLOCATION.  183 

some  cases,  however,  it  may  be  thought  preferable  to  make  a 
valvular  opening,  or  to  draw  off  the  pus  by  means  of  the  aspirator. 

The  importance  of  hygienic  conditions  and  constitutional  treat- 
ment cannot  be  over-estimated.  The  patient  should  have  plenty 
of  sunlight  and  pure  air — if  possible,  at  the  seaside  ;  a  liberal  but 
regulated  diet ;  and  sufficient  clothing.  If  he  is  able,  he  should 
move  about  on  crutches,  or  be  driven  in  a  carriage.  He  should 
take  alteratives — occasional  doses  of  grey  powder  and  rhubarb, 
for  example — with  cod-liver  oil,  or  the  preparations  of  iodine  or 
of  iron.     (Fig.  45,  47,  66.) 

In  cases  where  there  has  been  long-standing  suppuration,  and 
where  there  are  sinuous  tracks  leading  to  bare  bone,  the  head  of 
the  femur  may  be  excised  with  great  advantage.  At  the  same 
time  any  necrosed  bone  that  is  found  in  or  around  the  acetabulum 
may  be  removed.  Hancock  was  the  first  to  show  how  freely  this 
might  be  done. 

IXTOUM-BS  OF  JOINTS 

are  known  by  the  escape  of  synovia.  They  should  never  be 
probed ;  but  the  part  should  be  secured  by  a  splint,  and  kept 
perfectly  at  rest. 

The  prognosis  depends  upon  the  extent  of  the  injury,  the  size 
of  the  joint,  and  the  constitution  of  the  patient. 

Treatment. — If  the  wound  is  small,  it  should  be  at  once  closed, 
and  ice  continuously  applied  to  the  joint.  If  it  is  larger,  sup- 
puration is  likely  to  occur.  In  such  a  case  the  antiseptic  treat- 
ment ought  to  be  thoroughly  carried  out,  and  every  local  and 
constitutional  means  should  be  employed  for  allaying  the  inflam- 
mation. If  one  of  the  large  joints,  particularly  the  knee,  is  freely 
opened,  excision  or  amputation  may  have  to  be  performed  ;  though 
not  a  few  cases  are  on  record  which  may  well  encourage  the  sur- 
geon, even  here,  to  try  what  can  be  done  by  absolute  rest  and 
strict  antiseptic  dressings. 

BISIiOCATIOIT 

signifies  the  misplacement  of  the  bones,  entering  into  the  com- 
position of  a  joint.  The  distal  bone  is  said  to  be  dislocated  from 
the  proximal. 

Dislocation  may  be  partial  or  complete.  The  articular  surfaces 
may  be  entirely  displaced,  as  in  dislocation  of  the  hip ;  or  they 
may  be  partially  displaced,  as  we  sometimes  see  in  dislocation  of 
the  knee.  Again,  the  dislocation  may  be  simple,  or  it  may  be 
compound,  communicating  with  the  outer  air  by  means  of  a 
wound  in  the  skin.  Again,  it  may  be  complicated  with  fi'acture, 
or  with  ruptured  vessels. 


184  DISEASES  OF  TISSUES  AND  ORGANS. 

Dislocation  is  most  common  during  adult  life.  In  the  young 
and  old  the  bones  are  more  apt  to  break.  It  also  occurs  more 
often  in  men  than  in  women. 

Like  fracture,  it  may  be  caused  either  by  direct  violence  or  by 
muscular  action.  The  lower  jaw  and  the  patella  are  not  unfre- 
quently  dislocated  in  the  latter  way. 

When  a  dislocation  has  once  occurred,  it  is  apt  to  occur  again 
from  comparatively  trivial  causes.  The  writer  knew  a  lady  who 
dislocated  her  shoulder,  and  for  many  months  afterwards  the  bone 
would  slip  out  of  its  place  on  any  slight  exertion. 

The  signs  of  dislocation  are,  distortion  of  the  limb  or  part,  loss 
of  power,  immobility,  and  an  irregular  and  unnatural  outline 
of  the  joint.  In  some  cases  there  is  lengthening,  in  others 
shortening. 

Dislocation  is  of  necessity  attended  by  the  rupture  of  the  capsule 
of  the  joint  or  of  the  ligaments,  and  laceration  of  the  soft  tissues. 
Though,  in  all  ordinary  cases,  these  injuries  are  subcutaneous,  and 
hidden  from  view,  yet  they  must  not  on  that  account  be  overlooked. 
Treatment. — A  dislocation  should  be  reduced  as  early  as  possible. 
The  aim  of  all  treatment  is  to  bring  the  articular  surfaces  into 
such  a  position  that  the  muscles  may  be  able  to  restore  them  to 
their  proper  places. 

The  great  difficulty  is  to  overcome  the  contraction  of  the 
muscles.  In  recent  cases  this  may  often  be  done  by  mere 
manipulation  J  but  in  other  instances  gradual  extension, 
either  by  manual  power  or  by  means  of  pulleys,  will  generally 
be     required.       In      order      to      obtain      a      firm      purchase 

upon  the  part  without  unduly 
^^S*      ■  constricting  it,  it  is  customary 

to  apply  the  extending  force  by 
means  of  a  "clove-hitch,"  There 
are  various  ways  of  making  this 
knot;  perhaps  the  simplest  is 
that  which  is  here  represented. 
The  surgeon  takes  the  cord  or 
Clove-hitch.  j|      ^       bandage,  and  casts  a  loop  upon 

it.  This  he  fixes  with  his  left 
hand  ;  then  with  his  right  he  casts  a  second  loop  exactly  like  the 
first  (Fig.  84  a),  and  this  he  passes  across  so  as  to  bring  it  above 
the  first  loop  (Fig.  84  h). 

In  more  severe  cases  of  dislocation,  it  will  be  necessary  to  relax 
the  muscles  by  putting  the  patient  under  the  influence  of  chloro- 
form. Indeed  in  all  cases  of  dislocation  anaesthetics  are  a  great 
assistance  to  the  surgeon,  and  may  save  him  much  labour  and  the 
patient  much  unnecessary  pain  and  alarm. 


DISLOCATION  OF  THE  LOWER  JAW,  185 

A  second  difficulty  arises  from  the  shape  of  the  articulation 
itself:  thus  the  margins  of  the  acetabulum  present  an  obstacle, 
which  has  to  be  surmounted  before  the  head  of  the  femur  can  be 
restored  to  its  socket.  This  difficulty  must  be  overcome  by 
bearing  in  mind  the  relation  of  the  parts,  and  applying  the 
manipulation,  or  the  extending  force,  accordingly. 

If  a  dislocation  is  left  unreduced,  the  old  socket  is  gradually 
filled  up  or  absorbed,  and  a  new  one  is  formed,  lined  v/ith  a 
layer  of  fine  dense  tissue,  like  ivory  or  porcelain.  Fresh  liga- 
ments supply  the  place  of  the  old,  and  in  time  the  patient  gets 
a  very  useful  joint. 

Compound  dislocation  is  a  most  severe  injury,  and  one  which 
calls  for  great  judgment  on  the  part  of  the  surgeon.  If  it  is  one 
of  the  larger  joints  which  is  aflected,  and  the  patient  is  old  or 
debilitated,  amputation  may  have  to  be  performed ;  but  if  the 
patient  is  young  and  in  good  health,  an  attempt  may,  perhaps,  be 
made  to  reduce  the  dislocation  and  to  save  the  limb. 

A  compound  dislocation  of  one  of  the  smaller  joints  must  be 
reduced,  and  then  treated  on  the  same  principles  as  a  compound 
fracture. 

Dislocation  may  he  distinguished  from  fracture  by  attention 
to  the  following  points  : — 1.  The  absence  of  crepitus.  2.  The 
dislocated  part  is  unusually  fixed  and  immovable ;  whereas  in  a 
fracture  there  is  unnatural  mobility.  3.  A  fractured  bone  may 
be  easily  replaced,  but  there  is  great  difficulty  in  keeping  it  in 
position ;  whereas  when  a  dislocation  is  once  reduced,  it  remains 
in  place.  4.  A  broken  bone  is  generally  shortened,  but  a 
dislocated  one  is  unaltered  in  length. 

WTien  fracture  and  dislocation  co-exist,  the  rule  is  to  put  up 
the  fracture  firmly  in  splints,  and  then  reduce  the  dislocation.  If 
the  dislocation  is  left  till  the  fracture  has  united,  it  wiU  probably 
be  found  impossible  to  reduce  it. 

DZSIiOCATZOM-  OF  TBB  IiOlVER  JAW. 

The  lower  jaw  is  occasionally  dislocated  by  direct  violence,  but 
more  frequently  by  muscular  action — by  the  sudden  and  spas- 
modic action  of  the  external  pterygoid,  at  the  moment  when  the 
mouth  is  wide  open  in  yawning,  laughing,  &c.  The  condyle  is 
drawn  forwards  into  the  zygomatic  fossa.  This  may  occur  on 
one  side  only,  or  on  both. 

Si^ns. — The  chin  is  protruded,  the  mouth  is  open,  speech  and 
deglutition  are  very  imperfect,  saliva  flows  from  the  mouth,  and 
the  condyle  can  be  felt  under  the  zygomatic  arch.  When  one 
side  only  is  aflfected,  the  signs  are  less  distinct.  The  chin  is  then 
pointed  to  the  sound  side. 


186 


DISEASES  OF  TISSUES  AND  ORGANS. 


Treatment. — Our  aim  is  to  direct  the  condyle  downwards  and 
backwards.  With  this  view,  the  surgeon  protects  his  thumbs 
with  a  napkin,  and  then  introduces  them  on  the  inside  of  the 
molar  teeth  on  both  sides.  By  this  means  he  is  able  to  lay  firm 
hold  of  the  angles  of  the  jaw,  which  he  bears  downwards  and 
backwards,  at  the  same  time  that  he  raises  the  point  of  the  chin 
with  his  fingers,  Swain  recommends  another  method:  "Place 
the  patient  on  the  floor  with  his  head  between  yoiar  knees.  Then 
put  two  pieces  of  cork  as  far  back  as  possible  between  the  molars 
on  either  side.  Press  the  point  of  the  chin  steadily  and  directly 
upwards"  (Emergencies,  p.  13).  After  the  dislocation  has  been 
reduced,  the  patient  should  wear  a  four-tailed  bandage  upon  the 
chin  for  a  suflacient  time  to  prevent  recurrence. 

BISIiOCATIOir  OF  TBB  CX.AVXCI.E. 

The  sternal  end  of  the  clavicle  may  be  displaced  either 
forwards,  or  backwards,  or  upwards — in  front  of  the  sternum, 
behind  it,  or  above  it. 

The  treatment  consists  in  making   extension  by  putting  a  pad 

in  the  axilla,  or  by  drawing 
^^"  the    shoulders  back,    as   in 

fracture,  and  then  keeping 
the  end  of  the  bone  in  its 
place  by  a  suitable  arrange- 
ment of  pads  and  bandages. 

The  outer  end  of  the  bone 
is  generally  dislocated  up- 
wards on  to  the  acromion. 
Sometimes  the  bones  are 
merely  separated  without 
any  over-riding,  there  being 
only  a  small  gap  into  which 
the  point  of  the  finger  can 
be  pressed.  In  these  cases, 
as  it  is  the  acromion  which 
is  forced  away  from  the 
clavicle,  it  seems  more  in 
harmony  with  the  general 
rule  to  speak  of  the  injury  as 
dislocation  of  the  scapula.  Fig.  85  represents  such  a  case,  the 
particulars  of  which  1  have  reported  in  the  Lancet  for  June 
28,  1873. 

The  treatment  must  be  conducted  on  the  same  principles  as  in 
the  preceding  case. 

Although  it  is  easy  to  reduce  a  dislocation  of  the  clavicle,  it  is 


Dislocation  of  the  scapula. 


DISLOCATION  OF  THE  SHOULDER. 


187 


extremely  diiBcult  to  keep  the  bone  in  its  proper  place.  Indeed, 
it  is  probable  that  some  slight  amount  of  deformity  will  always 
be  left  after  this  accident. 

BISXiOCATIOIO-S  OF  THE  SHOUZiDER 

are  more  frequent  than  those  of  any  other  joint.  This  arises 
from  the  shallowness  of  the  glenoid  cavity,  the  size  and  shape 
of  the  head  of  the  humerus,  the  extent  of  its  movements,  and 
the  position  of  the  joint,  which  is  not  only  much  exposed  to 
direct  violence,  but  has  also  to  bear  the  shock  of  falls  on  the 
hand. 

The  shoulder  is  liable  to  three  dislocations : — (1)  forivards, 
beneath  the  coracoid  process  or  the  clavicle  (subcoracoid  or  subclavi- 
cular) ;  (2)  dotvmoards,  into  the  axilla  (subglenoid) ;  (3)  back- 
wards, on  to  the  dorsum  of  the  scapula. 

Sig7is. — Whatever  may  be  the  precise  nature  of  the  injury, 
there  is  pain,  loss  of  power,  and  immobility ;  the  shoulder  has 
lost    its    roundness,  and 

looks  angular  ;  the  aero-  ^^S-  ^^^ 

mion  projects,  and  there 
is  a  marked  depression 
below  it;  the  bead  of 
the  bone  may  be  felt  in 
an  unnatural  situation. 

But  besides  these 
signs  which  are  common 
to  all  the  varieties,  each 
has  its  own  peculiar 
marks. 

In  the  first  variety, 
the  head  of  the  humerus 
may  be  both  seen  and 
felt  below  the  clavicle, 
the  arm  is  shortened, 
and  the  elbow  points 
outwards  and  backwards 
(Fig.  86).  This  dis- 
location is  the  most 
common  of  all. 

In  the  second,  the 
head  of  the  humerus 
may  be  felt  in  the 
axilla,  the  arm  is 
lengthened,  the  elbow  points  outwards,  and  there  is  numbness 
from  pressure  on  the  axillary  plexus  of  nerves. 


Dislocation  of  the  shoulder,  forwards. 


188  DISEASES  OF  TISSUES  AND  ORGANS. 

In  the  third,  the  head  of  the  humerus  may  he  felt  on  the 
dorsum  of  the  scapula,  and  the  elbow  points  forwards. 

It  has  been  the  custom  of  surgeons  to  follow  Sir  Astley 
Cooper^s  classification,  and  to  describe  a  partial  dislocation, 
wherein  the  head  of  the  humerus  was  said  to  rest  on  the  edge 
of  the  glenoid  cavity  and  the  coracoid  process.  But  it  seems 
certain  that  no  such  dislocation  can  take  place,  and  that  the 
specimens  upon  which  Sir  Astley  Cooper  founded  his  opinion 
were,  in  truth,  cases  of  rheumatic  arthritis  in  which  the  glenoid 
cavity  was  expanded  (see  Mr.  Ed.  Owen's  paper  in  Med.  Chir. 
Trans.,  1875). 

Treatment  of  dislocation  forwards. — The  patient  should  he 
stripped,  and  laid  flat  upon  a  couch.  If  need  be,  he  should 
be  placed  under  the  influence  of  chloroform.  The  surgeon 
having  taken  off"  his  boot,  seats  himself  on  the  margin  of  the 
couch,  facing  his  patient,  and  having  grasped  the  dislocated  limb 
at  the  wrist  with  both  his  hands,  he  places  his  near  foot  in  the 
arm-pit,  so  that  the  hollow  of  the  foot  fits  into  the  fold  of  the 
axilla.  He  then  draws  the  arm  slowly  downwards  and  inwards, 
at  the  same  time  that  he  presses  steadily  with  his  foot. 

If  more  force  is  required,  a  jack-towel  may  be  fastened  round 
the  arm  above  the  elbow  by  means  of  the  "  clove-hitch,"  so  that 
an  assistant  may  draw  upon  it ;  or  the  pulleys  may  be  applied. 

The  same  principle  of  reduction  may  be  carried  out,  by  seating 
the  patient  in  a  chair,  the  surgeon  standing  beside  him,  and 
placing  his  knee  in  the  axilla,  while  he  bends  the  arm  over  it ;  or 
the  back  of  the  chair,  well  padded,  may  be  used  as  the  fulcrum, 
and  the  head  ol'  the  bone  raised  into  its  place  by  using  the 
humerus  as  a  lever. 

After  reduction,  a  pad  should  be  placed  in  the  axilla,  the  upper 
arm  bandaged  to  the  side,  and  the  fore-arm  carried  in  a  sling  for 
two  or  three  weeks,  or  for  a  sufficient  length  of  time  to  prevent 
the  joint  from  (as  it  were)  forming  a  habit  of  becoming  dislocated 
by  slight  accidents. 

The  other  varieties  of  dislocation  at  the  shoulder-joint  may  be 
reduced  by  extension  downwards ;  though,  in  each  case,  the  direc- 
tion of  the  extending  force  will  have  to  be  slightly  modified  to 
suit  the  particular  position  of  the  bones.  The  dislocation  down- 
wards (subglenoid)  is  sometimes  reduced  by  raising  the  arm  and 
drawing  it  upwards.  The  patient  is  laid  flat  on  his  back,  the 
shoulder  is  fixed  by  the  hand  of  the  operator,  or  by  a  jack-towel 
thrown  around  it,  the  arm  is  raised  by  the  side  of  the  head, 
and  traction  is  made  either  by  manual  or  mechanical  force  until 
the  head  of  the  bone  is  lifted  into  its  socket. 

After  the  lapse  of  three  months,  it  is  almost  hopeless  to  attempt 


DISLOCATION  OF  THE  WRIST.  189 

the  reduction  of  a  dislocated  shoulder.  If  the  patient  has  begun 
to  move  his  arm,  and  a  false  joint  has  been  already  in  some  mea- 
sure established,  the  surgeon  had  better  not  interfere.  The  most 
serious,  and  even  fatal,  consequences  may  follow  an  injudicious 
attempt  at  reduction. 

DZSZ.OCATZOM'S  OF  THE  EXiBOW 

are  commonly  the  result  of  great  violence.  They  are,  therefore, 
likely  to  be  attended  with  much  inflammation,  and  are  often 
associated  with  fracture. 

They  may  be  considered  under  three  heads ; — (1)  the  disloca- 
tion of  both  bones  ;  (2)  those  of  the  ulna  alone ;  (3)  those  of  the 
radius  alone. 

(1)  Both  bones  maybe  6\sip\aced  either  hacJctoards  or  forwards. 
In  the  former  case,  the  coronoid  process  is  very  likely  to  be 
broken ;  and,  in  the  latter,  the  olecranon.  In  both  cases,  the 
diagnosis  must  be  established  by  a  careful  comparison  of  the 
relative  situation  of  the  bony  points  in  the  two  arms.  If  there 
is  much  swelling,  it  is  often  extremely  difficult  to  determine 
accurately  the  nature  of  the  injury. 

(2)  The  ulna  may  be  dislocated  lacJcivards.  When  this 
happens  the  point  of  the  olecranon  projects  unnaturally,  and 
there  is  a  hollow  above  it.  The  elbow  is  fixed  at  a  right  angle. 
That  the  radius  is  not  implicated  may  be  ascertained  by  prona- 
tion and  supination.  Here,  too,  the  coronoid  process  is  very 
liable  to  be  broken. 

(3)  The  only  dislocation  of  the  radius  which  we  need 
mention  is  the  dislocation  forivards  on  to  the  external  condyle, 
though  it  is  occasionally  dislocated  backwards,  and  sometimes 
outwards. 

Treatment. — If  the  ulna  is  dislocated  with  fracture  of  either 
of  its  processes,  it  will  be  easy  by  extension  or  by  flexion  to 
restore  the  bones  to  their  proper  position,  though  it  may  be  very 
difficult  to  keep  them  in  situ.  But  if  the  ulna  is  dislocated 
without  fracture,  reduction  will  be  a  more  difficult  matter.  It 
may,  however,  be  effected  by  bending  the  elbow  across  the 
surgeon^s  knee,  which  he  uses  as  a  fulcrum.  In  the  dislocation 
of  the  radius,  the  arm  should  be  extended,  while  the  head  of  the 
bone  is  pressed  down  into  its  place. 

After  reduction,  the  arm  should  be  fixed  upon  an  angular 
splint,  and  carried  in  a  sling. 

SISXiOCATZOIT   OF  THE  VTllZST 

is  extremely  rare.  The  styloid  processes  of  the  radius  and  ulna, 
by  their  undue  prominence  indicate  the  nature  of  the  accident. 


190 


DISEASES   OF  TISSUES  AND  OEGANS. 


It  must  be  carefully  distinguished  from  fracture  of  the  lower 
end  of  the  radius  (Colles's  fracture). 

The  treatment  consists  in  extending  the  joint,  and  then  apply- 
ing a  flat  splint. 

BISlLOCATZOirS  OF  THE  HAITB. 

The  metacarpal  bone  of  the  thumb,  and  the  phalanges  of  the 
thumb  or  of  the  fingers,  are  sometimes  dislocated.     These  acci- 
-p-      gy  dents     are,     however, 

rare,  owing  to  the 
strength  of  the  lateral 
ligaments.  The  accom- 
panying Figure,  87, 
represents  a  dislocation 
of  the  metacarpal  bone 
of  the  thumb.  It  was 
easily  reduced  under 
Dislocation  of  the  thumb.  chloroform.    In    severe 

injuries  of  the  hand  the  phalanges  may  be  carried  either  backwards 
or  forwards.  1  have  seen  the  phalanges  of  the  two  middle  fingers 
dislocated  backwards  with  a  large  wound  in  the  palm.  The  heads 
of  the  metacarpal  bones  were  cut  off,  and  the  dislocation  reduced. 
The  treatment  consists  in  making  extension  by  means  of  a 
tape,  or  narrow  bandage,  fastened  to  the  finger  by  the  "  clove- 
hitch,"  and  then  securing  the  finder  upon  a  splint.  In  some 
cases  it  has  been  found  necessary  to  divide  the  lateral  ligaments 
subcutaneously  before  reduction  could  be  eflfected. 

BZSIiOCATION-S  OF  THE  HIP 

are  four  in  number  : — 

(1)  Dislocation  upwards,  on  to  the  dorsum  ilii. 

(2)  Dislocation  downwards,  into  the  obturator  foramen. 

(3)  Dislocation  forwards,  on  to  the  pubes. 

(4)  Dislocation  backwards,  into  the  sciatic  notch. 

1.  Dislocation  upwards,  on  to  the  dorsum  ilii. — This  is  the 
most  common  of  all.  The  head  of  the  femur  rests  on  the  smooth 
surface  immediately  above  and  behind  the  acetabulum.  In  this 
situation  it  forms  a  prominence  which  may  be  felt,  especially  on 
rotating  the  limb.  There  is  loss  of  power,  and  distinct  shortening. 
The  thigh  is  slightly  flexed  on  the  pelvis,  and  the  leg  on  the 
thigh.  The  knee  points  towards  its  fellow  of  the  opposite  side, 
and  the  foot  is  turned  inwards. 

2.  Dislocation  downwards,  into  the  ohturator  foramen,  is 
marked  by  lengthening.  The  leg  is  abducted.  The  toes  point 
forwards,  and  sometimes  a  little  outwards.     The  trunk  is  bent 


DISLOCATIONS  OF  THE  HIP.  191 

forwards,  by  the  tension  upon  the  psoas  and  iliacus  muscles. 
The  prominence  of  the  trochanter  is  lost.  The  head  of  the  bone 
may  be  felt  in  its  new  situation. 

3.  Dislocation  fomoards,  on  to  the  pubes. — Here  the  promi- 
nence of  the  trochanter  is  gone;  the  limb  is  shortened  and 
abducted ;  the  toes  point  outwards,  and  the  head  of  the  bone  can 
be  distinctly  felt  above  Poupart's  ligament. 

4.  Dislocation  backwards,  into  the  sciatic  notch,  presents 
much  the  same  signs  as  the  first  form  of  dislocation,  only  they 
are  not  so  well  marked,  because  the  head  of  the  bone  drops  into 
the  sciatic  notch,  instead  of  resting  on  the  dorsum  ilii.  The 
direction  of  the  limb,  too,  in  this  dislocation,  is  more  oblique 
than  in  the  former ;  the  afiected  thigh  points  across  the  middle 
of  the  opposite  one. 

Treatment. — The  patient  should  be  anaesthetized,  and  laid  on 
his  back  on  a  mattress,  placed  on  the  floor.  The  pelvis  should  be 
fixed  by  means  of  a  jack-towel,  passed  under  the  perineum,  and 
fastened  to  a  staple  in  the  floor.  A  belt  should  be  attached  to 
the  lower  part  of  the  femur,  and  connected  with  the  pulleys. 
The  extending  force  should  then  be  applied  slowly  and  gradually 
in  the  direction  of  the  axis  of  the  limb,  until  the  resistance  of 
the  muscles  is  overcome.  At  the  same  time,  the  leg  should  be 
rotated  outwards,  or  manipulated  in  such  a  way  as  shall  facilitate 
the  object  in  view.  In  some  cases  it  may  be  necessary  to  pass 
another  towel  between  the  thighs,  so  as  to  abduct  the  upper  part 
of  the  femur,  and  lift  the  head  of  the  bone  over  the  edge  of  the 
acetabulum. 

After  reduction,  the  patient  should  be  confined  to  bed 
for  a  fortnight;  a  long  splint  should  be  applied  to  his  leg  in  the 
usual  way,  and  secured  by  an  additional  bandage  round  the 
hips. 

After  six  weeks  have  elapsed  it  is  almost  hopeless  to  attempt 
the  redaction  of  a  dislocated  hip. 

But  these  older  methods  have  been  well-nigh  superseded,  at 
least  for  all  recent  cases,  by  manipulation.  When  the  patient  is 
fully  under  the  influence  of  an  anaesthetic,  the  muscles  are  so  re- 
laxed that  the  surgeon  can  deal  with  the  parts  in  a  merely 
mechanical  manner.  Bearing  in  mind  the  relative  anatomy  of 
each  dislocation,  and  using  the  femur  as  a  lever,  he  endeavours  to 
impress  such  movements  upon  the  head  as  shall  roll  it  into  the 
acetabulum.  Speaking  generally,  so  far  as  the  method  of  reduc- 
tion by  manipulation  is  concerned,  the  four  dislocations  may  be 
divided  into  two  groups — the  iliac  and  the  sciatic  dislocations, 
which  he  behind  the  joint ;  and  the  obturator  and  the  pubic,  which 
lie  in  front  of  it.     The  patient  should  be  laid  upon  a  hard  couch 


192  DISEASES  OF  TISSUES  AND  OEGANS. 

or  upon  a  mattress  spread  on  the  floor.  The  surgeon  then  takes 
a  firm  hold  of  the  ankle  and  knee,  and  proceeds  to  his  manipula- 
tions. In  the  case  of  the  iliac  and  sciatic  dislocations,  he  flexes 
the  leg  on  the  thigh,  and  the  thigh  on  the  abdomen,  at  the  same 
time  bearing  it  well  over  towards  the  opposite  sideof  the  body.  Then 
with  a  semi-circular  sweep  he  brings  it  towards  himself,  carrying 
it  almost  to  a  right  angle  with  the  afi'ected  hip,  and  then 
straightens  it  out  to  full  extension.  In  other  words,  flexion, 
adduction,  abduction,  and  extension  rapidly  succeed  one  another. 
In  the  case  of  the  other  two  dislocations,  the  obturator  and  the 
pubic,  the  thigh  is  flexed  on  the  abdomen,  but  bearing  away  from 
the  mesial  Hue.  It  is  then  by  a  semi-circular  sweep  carried  across 
the  body,  and  brought  down  to  full  extension.  It  is  surprising 
how  easily  a  recent  dislocation  slips  into  place  by  manipulation. 
It  is  only  in  cases  which  are  not  taken  in  hand  till  some  days  or 
some  weeks  have  elapsed  that  extension  by  pulleys  can  be  required. 

SISIiOCATIOXT  OF  THE  PATEIiIiA. 

The  patella  is  sometimes  dislocated  outwards,  on  to  the  outer 
side  of  the  external  condyle. 

This  accident  is  apt  to  occur  from  muscular  violence  in  persons 
who  are  knock-kneed. 

Signs. — The  knee  is  extended  or  slightly  bent.  A  depression 
may  be  felt  in  the  front  of  the  joint,  while  the  patella  can  be 
detected  in  its  new  situation. 

The  treatment  consists  in  relaxing  the  extensor  muscles  by 
flexing  the  thigh  on  the  pelvis  and  raising  the  leg.  Then,  by 
means  of  a  little  manipulation,  the  bone  may  be  restored  to  its 
proper  place.  After  reduction,  the  patient  should  wear  a  ban- 
dage, or  an  elastic  knee-cap,  for  a  few  weeks. 

Occasionally  the  patella  is  displaced  inwards;  and  in  some 
rare  instances  it  is  turned  half  round,  so  that  its  outer  edge 
points  forwards,  and  presents  a  sharp  ridge  under  the  skin.  Mr. 
Bellamy  has  recorded  a  case  of  this  kind.  A  young  man,  in 
jumping  out  of  a  cart,  caught  his  foot  on  the  rail,  and  fell.  There 
was  great  deformity  at  the  knee.  The  patella  was  dislocated  on 
its  inner  edge,  with  the  articular  surface  turned  outwards.  By 
extreme  extension  under  chloroform  it  was  soon  reduced,  but 
synovitis  followed.  Ultimately  the  patient  perfectly  recovered 
(Brit.  Med.  Jour.,  Jan.  4,  1873). 

I>ISZ.OCATXOIir  OF  TKS  SEMXIiVia-AS 
CARTZIiAGES 

sometimes  occurs  in  consequence  of  a  sudden  and  violent  wrench. 
If  the  cartilage  is  compressed  between  the  tibia  and  the  femur,  it 


DISLOCi^TION   OF  THE  ASTRAGALUS.  193 

gives  rise  to  intense  pain,  and  the  patient  is  unable  to  stand,  or  to 
move  his  knee. 

The  treatment  is  unsatisfactory,  and  the  case  must  often  be 
left  to  Nature.  It  is  difficult  to  reach,  and  to  act  upon,  the  semi- 
lunar cartilages.  By  rotating  the  tibia  on  its  axis,  the  surgeon 
may  sometimes  succeed  in  restoring  the  parts  to  their  proper 
positions. 

DISIiOCATIOXTS  OF  THE  KM'EE-TOIN'T 
are  the  result  of  great  violence,  and  are  more  often  compound,  or 
complicated,  than  simple.  Nevertheless,  the  tibia  may  be  dis- 
placed hacTcioards,  or  forwards,  or  to  either  side.  These  disloca- 
tions are  generally  incomplete,  and  accompanied  by  more  or  less 
rotation. 

Meduetion  is  made  by  flexing  the  thigh,  fixing  it  in  that  posi- 
tion, and  then  making  extension  by  drawing  from  the  ankle. 
When  this  is  done,  and  a  little  pressure  used,  the  bones  may, 
in  most  cases,  be  restored  to  their  proper  situations  without 
difficulty. 

Not  unfrequently  the  knee-joint  is  dislocated  by  disease.  In 
these  cases,  the  tibia  is  generally  drawn  backwards  and  upwards. 

DZSIiOCATZON-  OF  THE  AITKIiE 

consists  in  the  separation  of  the  astragalus,  carrying  with  it 
the  foot,  from  the  bones  of  the  leg.  This  injury  can  hardly 
occur  without  fracture  of  one  or  both  malleoli. 

The  foot  may  be  displaced  hacJcwards,  or  forwards,  or  to  either 
side.  The  dislocation  outwards,  with  fracture  of  the  external 
malleolus,  is  the  most  common  (Pott's  Fracture,  see  p.  168). 

In  all  cases,  reduction  must  be  effected  by  drawing  upon  the 
foot  until  the  bones  are  brought  into  their  positions,  and  then 
fixing  them  by  means  of  side-splints,  or  a  M'Intyre's  splint,  as  the 
case  may  require. 

BISZiOCiLTZOM-  OF  THE  ASTRAGAZiUS 

may  take  place  either  forwards,  or  hacTcwards.  Of  these  dis- 
placements the  former  is  the  most  common.  The  accident 
generally  happens  from  the  patient  falling  upon  his  foot,  when 
it  is  in  the  extended  position.  The  bone  may  usually  be  felt, 
either  on  the  instep,  or  in  the  space  between  the  tibia  and  the 
tendo  Achilhs. 

Reduction  may  sometimes  be  effected  by  simply  drawing  upon 
the  foot.  Sometimes  division  of  the  tendo  Achillis  may  be 
necessary. 

Not  unfrequently  it  will  be  found  impossible,  after  all,  to 
bring  the  bone  back  to  its  place.     In  such  a  case,  it  may  either 

(X 


194  DISEASES  OF  TISSUES  AND  ORGANS. 

be  excised  at  once,  or  left  to  itself.  If  left  to  itself,  it  is 
most  probable  that  the  skin  over  it  will  slough,  and  then  part  of 
the  bone  may  be  removed  with  the  saw  or  pliers,  or  else  allowed 
to  exfoliate.  Mr.  MacCormac  has  related  two  cases  of  dislocation 
backwards  and  inwards,  in  which  no  operation  was  performed,  and 
both  of  which  made  good  recoveries  (Path.  Soc.  Trans.,  1875). 

Mr.  Hancock  has  reported  a  case  in  which  an  excellent  result 
was  obtained  by  removing  the  bone  at  once,  and  treating  the 
wound  with  a  constant  stream  of  carbolic  acid  lotion  from  a 
syphon  bottle  (Lancet,  January  20,  1872). 

But,  in  truth,  the  dislocations  of  the  ankle  and  of  the  astragalus 
are  much  more  often  compound,  or  complicated,  than  simple.  If 
bony  points  protrude  through  the  skin,  and  cannot  be  reduced, 
they  must  be  sawn  off,  as  in  the  case  of  compound  fractures.  If 
the  soft  parts  are  extensively  lacerated,  or  if  the  main  vessels  are 
torn,  or  if  the  age  and  habits  of  the  patient  are  unfavourable,  the 
case  will  probably  require  amputation. 

Some  authors  speak  of  the  leg  as  being  dislocated  from  the  foot. 
This  mode  of  expression  is  often  strictly  correct,  for  it  frequently 
happens  in  the  accidents  which  lead  to  dislocation  of  the  ankle 
or  of  the  astragalus,  that  the  foot  is  the  fixed  point,  and  the  leg 
is  wrenched  from  it  by  the  weight  of  the  body.  But  it  is  more 
convenient  to  have  one  general  rule  applicable  to  the  whola 
body,  and  to  say  that  the  distal  part  is  dislocated  from  the 
proximal. 

ARTERITIS. 

Arteries  are  liable  to  become  inflamed,  and  such  inflammation 
may  be  either  limited  or  diffuse. 

Limited  arteritis  is  probably  excited  by  embolism,  ligature, 
wounds,  or  other  like  causes.  It  is  of  the  adhesive  kind,  and 
tends  to  the  occlusion  of  the  vessel. 

Diffuse  arteritis  is  a  blood  disease,  closely  allied  to  erysipelas  ; 
but  it  is  a  rare  affection — indeed,  so  rare  that  some  pathologists 
have  denied  its  existence  altogether,  and  have  attributed  the 
symptoms  during  life  to  a  blood  poisoning,  and  the  morbid  ap- 
pearances to  post  mortem  changes. 

Symptoms. — Local  pain  and  tenderness,  extending  perhaps 
some  distance  along  the  artery,  which  feels  hard  and  tense.  The 
part  which  it  supplies  may  become  cold  and  numb,  and  show 
signs  of  gangrene. 

Tlie  treatment  must  be  conducted  on  the  general  principles 
which  guide  us  in  dealing  with  inflammation. 


195 


DX:GEM'EX^A.TZOM-  OF  ARTERIES. 

There  are  two  forms  of  degeneration  to  which  arteries  are 
chiefly  liable — the  atheromatous  and  the  calcareous. 

"The  changes  in  the  arteries  known  as  atheromatous  have  their 
seat  in  the  deeper  layers  of  the  inner  coat.  In  the  earliest 
stage  of  the  inflammatory  process  the  fibrous  and  elastic  lamellae 
of  the  inner  coat  of  the  vessel  become  infiltrated  with  young  cells 
which  are  probably  partly  emigrants  and  partly  derived  from  the 
proliferation  of  the  cells  of  these  structures.  As  these  young 
cells  increase  in  number,  they  give  rise  to  a  swelling  beneath  the 
innermost  layers  of  this  coat  of  the  artery.  This  swelling  of  the 
intima  is  very  characteristic.  It  is  in  the  earlier  stage  of  the 
process  of  a  soft  flabby  consistence,  and  the  lining  membrane, 
which  is  continuous  over  it,  can  readily  be  stripped  off,  leaving 
the  diseased  tissue  beneath.  It  thus  contrasts  strongly  with  the 
superficial  patches  of  fatty  degeneration  which  result  fi'om  the 
passive  metamorphosis  of  the  endothelial  and  connective-tissue 
cells  of  the  vessel"  (Dr.  T.  H.  Green's  Pathology). 

This  process  gradually  extends,  until  large  irregular  patches 
are  formed.  These  patches  have  a  yellow  colour  and  a  cheesy 
cxDnsistence.  The  middle  coat  becomes  gradually  involved  in  the 
degeneration. 

Sometimes  the  young  cell-growth  softens  and  breaks  down, 
forming  what  has  been  termed  an  atheromatous  abscess  or  an 
atheromatous  ulcer.  In  other  instances,  the  more  liquid  consti- 
tuents of  the  degenerated  tissues  are  absorbed,  cholestrine  forms, 
and  the  debris  is  left  in  the  deeper  layers  of  the  inner  coat. 
This  may  afterwards  calcify,  and  thus  calcareous  plates  are 
formed.  This  calcareous  degeneration  (ossification  of  arteries) 
consists  in  the  deposit  of  earthy  matter — carbonate  and  phos- 
phate of  lime.  There  may  be  only  a  few  gritty  particles,  or  the 
whole  circumference  of  the  tube  may  be  rigid  from  the  cal- 
careous formation. 

The  two  forms  of  degeneration  are  often  associated  in  the 
same  individual,  and  even  in  the  same  artery. 

When  the  coats  of  an  artery  are  aftected  with  atheromatous 
or  calcareous  deposits  they  are  apt  to  give  way ;  they  lose  that 
elasticity  which  plays  an  important  part  in  carrying  on  the  cir- 
culation, and  the  calibre  of  the  vessel  is  diminished. 

Thus  it  happens  that  the  degeneration  of  arteries  leads  to  many 
morbid  conditions,  which  are  fruitful  sources  of  mortality,  espe- 
cially among  elderly  people.  Hinc  subitce  mortes  atque  intestata 
senectus  (Juv.  i.  1-44).     To  this  cause  we  may  trace  many  cases 

o  2 


196  DISEASES   OF  TISSUES  AND  QEGANS. 

of  aneurysm,  apoplexy,  cerebral  softening,  senile  gangrene,  and 
disease  of  the  heart.  A  man  who  has  passed  middle  age  should 
be  careful  to  put  no  sudden  or  excessive  strain  upon  his  tissues. 
He  should  bear  in  mind  that  his  arteries  are  not  so  elastic,  his 
joints  not  so  supple,  his  bones  not  so  tough,  as  once  they  were;  and 
his  activity  should  be  moderated  in  accordance  with  his  years. 
Taken  in  this  sense  there  is  much  truth  in  the  proverb  to  which 
Cicero  alludes  :  "  Be  an  old  man  betimes,  if  you  wish  to  be  an  old 
man  long"  (De  Senectute,  x.). 

AN-EURVSIVE, 

An  aneurysm  is  a  tumour  which  is  formed  by  the  rupture  or 
distension  of  the  coats  of  an  artery. 

It  is  a  disease  of  middle  life,  and  more  common  in  men  than 
in  women. 

Whatever  tends  to  impair  the  strength  and  elasticity  of  the 
arterial  walls  predisposes  to  aneurysm.  The  principal  exciting 
causes  of  the  disease  are  blows,  strains,  and  wounds. 

Mr.  Francis  H.  Welch,  Assistant  Professor  of  Pathology  at 
Netley,  has  carefully  studied  the  records  of  thirty-four  fatal  cases 
of  aortic  aneurysm  at  the  Royal  Victoria  Hospital,  and  finds  (1)  that 
they  were  all  associated  with  a  diseased  condition  of  the  internal 
and  middle  coats — a  tissue  growth  terminating  in  degeneration ; 
and  (2)  that  one  half  of  the  cases  occurred  in  patients  who  were 
undoubtedly  syphilitic,  and  of  the  rest  a  large  number  were  the 
subjects  of  acute  rheumatic  affections  or  of  alcoholism  (Med. 
Chir.  Trans.,  1876). 

There  are  various  kinds  of  aneurysm.  The  whole  calibre  of 
the  artery  may  undergo  gradual  dilatation  {fusiform  a.),  or  the 
enlargement  may  be  confined  to  a  part  [sacculated  a.).  Again, 
one  or  more  of  the  arterial  coats  may  remain  stretched 
over  the  tumour  (true  sacculated  a.),  or  all  the  coats  may 
have  given  way  (false  sacculated  a.).  Again,  when  all  the 
coats  have  been  ruptured,  the  blood  may  be  confined  in  a  sac 
formed  of  cellular  tissue  (circumscribed  a.),  or  it  may  spread  up 
and  down  the  part  (diffuse  a.).  If  the  blood  makes  its  way 
between  the  arterial  tunics  themselves,  it  is  called  a  dissecting 
aneurysm. 

True  aneurysms  are  generally  formed  by  the  rupture  of  the 
two  internal  coats,  and  the  dilatation  of  the  outer.  False 
aneurysms  are  often  the  result  of  punctured  wounds. 

It  has  long  been  the  custom  to  divide  aneurysms  into  these 
various  classes;  but,  in  truth,  the  classification  is  of  very  little  prac- 
tical value.  The  inflammatory  changes  attending  the  development 
of  atheroma  obliterate  the  nice  distinctions  between  the  arterial 


ANEURYSM. 


197 


Fis:.  88. 


tunics;  moreover,  the  patient  must  have  died,  or  an  operation 
must  have  been  undertaken,  before  any  opinion  can  be  formed 
as  to  the  integrity  of  the  coats  of  the  vessel. 

The  interior  of  the  sac  is 
hned  by  concentric  layers  of 
tibrine,  of  which  the  oldest 
are  the  whitest,  and  the  most 
condensed.  The  inner  ones 
are  darker  in  colour,  and 
more  loosely  compacted.  In 
a  fusiform  or  tubular 
aneurysm  no  such  deposit  of 
fibrine  takes  place. 

Si/7)}j)toms.  —  When  an 
aneurysm  presents  itself  ex- 
ternally there  is  usually  a  cir- 
cumscribed tumour  situated 
in  the  line  of  some  artery 
(Fig.  88).     It  is  tense,  but 


Aneurysm  of  carotid  artery. 


Fia;.  89. 


may  be  partially  emptied  by  pressing  on  the  vessel  above  it.  It 
pulsates,  and  expands  with  each  beat  of  the  heart.  This  expan- 
sive pulsation  is  very  characteristic. 
When  it  is  handled  it  often  com- 
municates a  thrill  to  the  fingers. 
With  the  stethoscope  a  distinct 
bruit  can  be  heard.  When  the 
circulation  is  arrested  the  pulsa- 
tion and  briiit  both  cease,  and 
return  again  as  soon  as  the  current 
is  re-established. 

Aneurysm  of  the  lower  part  of 
the  abdominal  aorta,  or  of  the  pelvic 
arteries,  though  it  presents  no  ex- 
ternal tumour,  may  be  felt  through 
the  parietes  (Fig.  89).  Aneurysm 
of  the  upper  part  of  the  abdomi- 
nal aorta,  and  of  the  intra-thoracic 
arteries,  falls  chiefly  under  the 
care  of  the  physician. 

If  left  to  itself,  an  aneurysm 
usually  goes  on  increasing ;  and  as 
it  increases,  its  pressure  causes 
absorption  of  everything  that  comes  in  its  way,  hard  and  soft 
tissues  alike.  At  length  it  reaches  a  free  surface — the  skin,  or  a 
mucous   or   serous  membrane — ulceration  takes  place,   and  an 


Aneurysm  of  abdominal 
aorta :  sac  laid  open. 


198  DISEASES  OF  TISSUES  AND  OEGANS. 

opening  is  formed,  through  which  the  blood  flows  more  or  less 
quickly,  and  leads  to  a  fatal  result.  Or,  if  it  is  situated  in  the  ex- 
tremities, the  aneurysm  may  burst,  and  the  blood  may  become  dif- 
fused through  the  cellular  tissue  of  the  limb ;  or  the  sac  may 
become  acutely  inflamed,  and  suppurate;  or  the  disease  may 
destroy  life  by  its  secondary  effects — for  example,  by  pressure 
upon  some  important  part,  as  the  trachea  or  oesophagus. 

In  a  few  fortunate  cases,  aneurysms  have  undergone  a  spon- 
taneous cure.  This  may  happen  from  coagulation  and  consolida- 
tion of  the  contents  of  the  sac,  or  from  plugging  of  the  aperture 
in  the  arterial  wall,  or  from  compression  of  the  artery  by  the 
tumour  itself. 

Treatment. — As  there  are  many  aneurysms  which  cannot  be 
reached  bj'  surgical  means,  it  is  important  to  consider  the  medical 
treatment  of  the  disease.  The  first  thing  to  be  done  is  to  re- 
strain the  patient's  activity ;  he  should  be  kept  much  at  rest  in 
the  recumbent  posture.  Then  he  should  be  put  upon  a  restricted 
diet,  our  object  being  to  avoid  everything  that  would  quicken 
the  circulation,  while  we  increase  the  plasticity  of  the  blood.  At 
the  same  time,  such  medicines  should  be  prescribed  as  will  allay 
irritability  and  excitement,  and  quiet  the  pulsations  of  the  heart. 
Balfour  has  strongly  recommended  the  use  of  iodide  of  potas- 
siiim. 

Of  the  surgical  means  of  treatment,  pressure  is  the  simplest 
and  safest.  Our  object  is  to  arrest,  or  to  diminish,  the  flow  of 
blood,  so  as  to  allow  the  contents  of  the  aneurysmal  cavity  to 
coagulate  and  solidify.  This  has  been  accomplished,  in  the  case 
of  popliteal  aneuryism,  by  merely  flexing  the  knee-joint.  But  it 
is  not  every  case  that  can  be  treated  in  this  simple  way.  More 
Fio-.  90  than  this  will  generally  be  required.     In  most 

cases  a  tourniquet  of  some  kind  will  have  to  be 
applied  to  the  artery  above  the  tumour.  Some- 
times the  flngers  of  an  assistant  answer  better 
than  anything.  The  pressure  need  not  be 
constant,  nor  need  it  always  be  applied  on  the 
same  spot.  It  may  be  shifted  a  little  up  and 
down  the  artery ;  and  if  it  is  exerted  for 
twelve  or  fifteen  hours  out  of  the  twenty-four, 
that  will  generally  be  found  quite  sufficient. 

Of  the  mechanical  tourniquets,  Signoroni's 

and  Carte's  are  the  most  convenient. 

Signoroni  s  tour-       Signoroni's    tourniquet    is    shaped    like    a 

'^  ^      *  horseshoe  (Fig.  90),  and  consists  of  two  limbs 

which  are  jointed  together  at  the  convexity,  and  which  can  be 

separated   or   approximated    by    a   screw   and    cog-wheel.     At 


ANEURYSM.  199 

one  extremity  of  the  horseshoe  is  a  small  convex  pad  which  is 
intended  to  be  placed  over  the  artery,  and  at  the  other  extremity 
is  a  large  concave  pad  which  forms  the  point  of  counter-pressure. 
This  tourniquet  has  the  advantage  of  only  making  pressure 
upon  tvjo  points,  and  leaving  the  rest  of  the  limb  free;  but, 
on  the  other  hand,  it  has  the  disadvantage  of  being  liable  to 
slip,  and  shift  its  position,  under  the  movements  of  the  patient. 

Carte's    tourniquet    has    been   variously  „. 

modified,   but  it  consists    essentially  of   a  „     ' 

broad  ring  which  passes  round  the  thigh, 
and  gives  support  to  an  upright  screw.  This 
screw  carries  a  pad  upon  its  lower  end,  and 
is  fitted  with  an  elastic  apparatus  which 
moderates  the  pressure  (Fig.  91).  The 
advantages  of  Carte's  tourniquet  are  that 
the  point  of  pressure  can  be  regulated  with 
great  nicety,  and  the  force  has  a  certain 
degree  of  elasticity. 

Carte's  and  Signoroni's  tourniquets  are  Carte's  tourniquet, 
sometimes  used  together,  or  in  pairs — the  two  instruments  being 
placed  side  by  side  at  a  short  distance  from  one  another,  so  that 
pressure  may  be  made  first  by  one  and  then  by  the  other.  In 
this  way  the  patient  is  saved  some  pain,  and  the  danger  of  chafing 
the  skin  is  avoided.  When  the  application  of  the  tourniquet  has 
to  be  left  to  imskilled  hands  it  is  a  good  plan  to  mark  out  the 
course  of  the  artery  with  ink,  or  with  a  solution  of  lunar  caustic, 
so  as  to  be  sure  that  the  pressure  is  always  exerted  in  the  proper 
line. 

Dr.  Wm.  Murray,  of  Newcastle,  recommends  that  the  flow  of 
blood  should  be  as  completely  arrested  as  possible  until  coagulation 
seems  to  have  taken  place,  and  that  then  the  patient  should  have 
complete  repose.  Of  late  years  appliances  have  been  introduced 
under  the  name  of  compressors  or  clamps,  for  the  purpose  of 
arresting  the  flow  of  blood  through  the  aorta  in  the  case  of  ab- 
dominal aneurysm.  Such  instruments  are  for  the  most  part 
modifications  of  Signoroni's  and  Carte's  tourniquets  on  an  enlarged 
scale.     One  of  the  best  is  Lister's. 

If  pressure  cannot  be  used,  or  if  it  has  been  tried  without 
success,  we  must  have  recourse  to  the  ligature.  The  artery  may 
be  tied  either  on  the  proximal  or  on  the  distal  side  of  the  tumour. 
As  a  general  rule  the  proximal  side  is  preferred,  at  a  point  well 
above  the  aneurysm  (Hunter's  operation).  It  is  only  in  excep- 
tional cases  that  the  surgeon  selects  the  distal  side  (Brasdor's 
operation).  The  ligature  may  be  applied  at  any  point  between 
the  aneurysm  and  the  next  large  branch  j  but  it  should  not  be 


200 


DISEASES   OF  TISSUES  AND   OEGANS. 


placed  too  near  the  tumour  on  the  one  hand,  nor  too  near  the 
branch  on  the  other. 

The  ligature  should  be  of  fine  whipcord,  or  of  catgut,  or  of 
Lister's  "  antiseptic  ligature."  It  should  be  introduced  with  as 
little  disturbance  as  possible,  and  should  include  nothing  but  the 
artery.  It  is  to  be  drawn  tight,  so  as  to  rupture  the  two  inner 
coats  of  the  vessel,  for  it  is  upon  this  that  the  process  of  cure,  and 
the  safety  of  the  patient,  depend. 

After  the  operation,  the  limb  should  be  kept  warm.  If  un- 
happily   gangrene    supervenes. 


Fig.  92. 


Popliteal  aneurysm. 


amputation  will  have  to  be  per- 
formed at,  or  above,  the  point  of 
ligature.  Fig.  92  represents  a 
section  of  a  popliteal  aneurysm. 
In  this  case  the  leg  was  ampu- 
tated on  account  of  gangrene. 

Other  methods  of  treating 
aneurysm  have  been  practised, 
varying  with  the  situation  and 
nature  of  the  tumour.  The  sac 
has  been  laid  open,  and  both 
ends  of  the  artery  ligatured — for 
example,  in  dealing  with  a 
gluteal  aneurysm.  Again,  the 
surfaces  of  the  sac  have  been 
rubbed  together,  in  the  hope  of 
detaching  some  flakes  of  fibrine 
which  might  obstruct  the  open- 


in  the  artery  (Fergusson's  method  of  manipulation).  Again, 
foreign  bodies  have  been  introduced  into  the  sac  in  the  hope  of 
promoting  the  deposit  of  fibrine.  Thus,  needles  have  been  passed 
through  in  various  directions.  A  fine  trochar  has  been  inserted, 
and  iron  wire  passed  into  the  sac.  In  this  manner  Mr.  C.  H. 
Moore  introduced  twenty-six  yards  of  fine  iron  wire  into  an  aortic 
aneurysm ;  and  more  recently  Mr.  Bryant  has  recommended  the 
introduction  of  horse-hair  or  fishing-gut. 

Again,  galvano-puncture  and  acupressure  are  among  the  most 
recent  suggestions. 

ANEURTSIVX  B7  AXTASTOMOSZS   (ITAIVUS) 

is  a  tumour  formed  by  the  dilated  condition  of  the  arterial  or 
venous  capillaries,  or  of  both  together.  When  arterial,  it  is  bright 
red,  tense,  and  pulsating.  When  venous,  it  is  soft,  and  of  a  blue  or 
purple  colour. 

It  is  generally  seen  about  the    face,  head,  or  neck,  and  its 


ANEUEYSM  BY  ANASTOMOSIS. 


201 


Fiff.  93. 


common  seat  is  the  skin,  or  subcutaneous  cellular  tissue.     It  is 
almost  always  congenital — "  a  mother's  mark." 

It  may  vary  in  size  from  a  mere  speck  to  a  large  irregular 
tumour.  Sometimes  it  is  cutaneous,  and  involves  only  the  skin  ; 
sometimes  it  is  mixed,  and  aifects  both  the  skin  and  the  subcu- 
taneous cellular  tissue.  Sometimes  it  is  subcutaneous,  and  does 
not  reach  the  skin  at  all.  When  it  is  confined  to  the  subcu- 
taneous cellular  tissue  the  diagnosis  is  not  always  easy.  Some- 
times a  naevus  is  enclosed  in  a  capsule  of  dense  areolar  tissue 
(especially  when  it  belongs  to  the  venous  subcutaneous  variety). 
Sometimes  it  has  no  defined  boundary.  Sometimes  it  remains 
stationary,  at  other  times  it  increases  rapidly. 

The  arterial  nasvus,  if  left  to  itself,  will  sometimes  undergo  a 
spontaneous  cure. 

The  treatment  varies  with  the  situation,  size,  and  character  of 
the  ngevus.  Sometimes  it  may  be 
destroyed  by  caustics — nitric  acid, 
for  example.  Sometimes  adhesive 
inflammation  may  be  excited  in  it 
by  pressure.  Sometimes  suppura- 
tive inflammation  may  be  set  up 
by  setons ;  sometimes  the  blood  may 
be  coagulated  by  the  injection  of  the 
tincture  of  the  perchloride  of  iron. 
To  introduce  threads  dipped  in  this 
tincture  is  the  best  way  of  dealing 
with  a  naevus  on  the  eyelids. 
An  orbital  naevus,  such  as  that 
represented  in  Fig.  93,  should  be  treated  with  the  small  cautery 
dehneated  in  Fig.  94.  The  bulb  of  the  instrument  is  heated  by 
a  spirit  lamp,  and  then  the  point  is  pushed  into  the  affected 
part.     This  is  done  as  often  as  the  surgeon  thinks  necessary,  and, 

Flo-.  94. 


Orbital  naevus. 


after  the  lapse  of  a  few  days,  the  operation  is  repeated,  until  the 
naevus  gradually  contracts  and  becomes  obliterated.  But  the 
most  convenient  way  of  dealing  with  a  naevus,  and  that  which 
is  applicable  to  the  great  majority  of  cases,  is  the  ligature.     A 


202  DISEASES   OF  TISSUES  AND  ORGANS. 

strong  silk  thread  is  passed  beneath  and  around  the  disease,  and 
tied  in  such  a  manner  as  to  strangulate  it.  This  may  be  done 
subcutaneously ;  and  much  ingenuity  has  been  expended  in  de- 
vising knots  that  are  suitable  to  different  cases.  Sometimes  the 
blood  supply  may  be  cut  off  by  acupressure  applied  to  the  main 
feeders,  as  in  a  case  reported  by  Mr.  Bellamy,  in  which  an 
extensive  nsevus  of  the  face  was  entirely  cured  by  obliterating 
the  facial,  coronary,  and  angular  arteries  by  acupressure;  or, 
finally,  excision  may  be  practised ;  but  this  is  a  hazardous  opera- 
tion, and  offers  no  special  advantage.  Of  all  these  methods  of 
treatment,  the  ligature  is  that  which  will  generally  be  found  the 
safest  and  best. 

PHIiEBZTZS. 

Veins  are  liable  to  inflammation,  and  such  inflammation  may 
be  either  circumscribed  or  diffuse. 

When  a  vein  is  inflamed  the  coats  become  thick  and  soft ;  and 
the  blood,  as  it  courses  along,  coagulates,  and  the  fibrine  is  de- 
posited. There  is  thrombosis.  The  vessel  is  plugged,  not  by 
the  effusion  of  plastic  lymph,  but  by  coagulated  blood.  There  is 
no  adhesive  inflammation,  as  was  formerly  held. 

If  now  this  blood-clot  softens  in  the  centre,  a  pus-like  fluid  is 
formed,  but  this  is  not  true  pus.  It  is  a  product  of  degeneration, 
not  of  inflammation.  There  is  no  suppurative  inflammation,  as 
was  formerly  held. 

But  the  inflammation  in  the  coats  of  the  vein  may  extend  to 
the  surrounding  areolar  tissue,  and  this  inflammation  may  run 
on  to  suppuration.  There  is  then  an  abscess  in  the  course  of  the 
vein,  and  this  may,  in  a  certain  sense,  be  called  suppurative 
phlebitis.  But  this  is  a  very  different  thing  from  the  old  doctrine, 
which  was  that  suppurative  inflammation  occurred  inside  the  vein. 

Inflammation  of  veins  is  often  the  result  of  an  injury  in  per- 
sons who  are  out  of  health.  Sometimes  it  follows  the  strain  of 
over-exertion.  In  many  instances  it  arises  spontaneously  in  con- 
nection with  gout  or  blood-poisoning ;  and  frequently  we  can 
assign  no  cause  except  general  weakness.  Externally  the  vein 
appears  red,  swollen,  and  knotty,  and  is  tender  and  painful. 

When  a  vein  is  plugged  by  a  thrombus  there  is  danger  lest 
particles  of  fibrine  should  be  washed  off,  carried  into  the  circula- 
tion, and  give  rise  to  embolism.  Savory  relates  the  case  of  a 
man,  aged  forty,  who  had  been  confined  for  some  weeks  to  his  room 
and  couch  with  thrombosis  of  the  femoral  vein.  One  evening, 
after  his  servant  had  assisted  him  into  bed,  he  asked  his  master 
if  he  could  do  anything  more  for  him  before  he  left  him  for  the 
night.     "No,  thank  you/'  was  the  answer;    and,  giving    the 


VARIX.  203 

affected  thigh  a  slap  with  his  open  hand,  he  added,  "  I  shall  be 
able  to  help  myself  now."  Before  the  man  could  leave  the  room, 
he  heard  the  sound  as  of  some  one  choking,  and,  looking  round, 
he  saw  his  master  fall  back,  and  suddenly  die. 

The  saphena  vein  is  very  apt  to  be  affected  by  phlebitis  in 
persons  who  have  varicose  veins ;  and  it  is  a  phlebitic  plugging 
of  the  iliac  and  femoral  veins  which  gives  rise  to  "  white  leg" 
(phlegmasia  dolens). 

When  the  phlebitis  is  diffuse  it  is  of  an  erysipelatous  kind,  and 
then  it  is  generally  associated  with  septicaemia. 

Treatment. — The  patient  should  rest  in  the  horizontal  position. 
The  part  should  be  fomented,  or  treated  (as  Savory  recommends) 
with  a  strong  lead  lotion  (one  part  of  liq.  plumbi  to  eleven  parts 
of  water).  Drugs  will  be  of  use  to  counteract  any  rheumatic  or 
gouty  tendency,  to  relieve  pain,  and  to  reduce  pyrexia.  An 
elastic  stocking  or  a  bandage  will  be  required  when  the  acute 
symptoms  have  been  subdued. 

In  the  diffuse  form  of  the  disease,  support  and  stimulants  will 
probably  be  required  from  the  first  (P.  34,  35,  100,  108). 

VARIX 

signifies  a  tortuous  and  dilated  condition  of  the  veins.  The  coats 
become  thickened,  and  the  valves  are  insufficient  for  their  purpose. 
The  affected  part  feels  heavy,  and  aches.  When  the  disease  is  more 
advanced  there  is  swelling  and  oedema,  with  very  severe  pain. 

This  condition  is  rarely  seen  in  the  deep  veins,  but  it  is  very 
common  in  the  superficial.  The  veins  of  the  leg,  which  have  to 
support  a  long  column  of  blood,  are  the  ones  which  are  most  often 
affected.  Sometimes  the  large  trunks  alone  are  dilated.  Some- 
times it  is  only  the  smaller  ones  which  become  varicose.  Some- 
times all  are  affected  alike.  The  limb  is  apt  to  become  swollen 
and  congested.  Then  the  skin  gives  way,  and  the  result  is  a 
varicose  ulcer.  Sometimes  the  veins  of  the  spermatic  cord  are 
affected  (varicocele),  and  then  the  pain  is  of  a  dragging  cha- 
racter ;  sometimes  those  of  the  rectum  (haemorrhoids),  and  this 
is  accompanied  with  intolerable  itching  and  smarting.  Of  these 
two  diseases  we  shall  speak  at  length  hereafter. 

Whatever  impedes  the  venous  circulation  tends  to  cause  varix 
— be  it  general  debility,  or  a  ligature,  or  the  pressure  of  a  tumour 
or  of  the  gravid  uterus,  or  a  faecal  accumulation,  or  anything  else. 

The  treatment  of  varicose  veins  in  the  leg  is  both  palliative  and 
curative.  The  palliative  treatment  consists  in  sponging  the  part 
every  morning  with  cold  water,  rubbing  the  leg  from  the  ankle 
to  the  knee — i.e.,  in  the  direction  of  the  venous  current — sup- 
porting the  veins  by  means  of  a  bandage  or  an  elastic  stocking. 


204  DISEASES  OF  TISSUES  AND  ORGANS. 

and  prescribing  an  occasional  aperient  iu    order  to  relieve  the 
portal  circulation. 

But,  if  the  veins  give  much  annoyance,  or  if  they  are  liable  to 
bleed,  or  if  they  are  associated  with  an  obstinate  ulcer,  we  may 
have  recourse  to  the  curative  treatment,  which  consists  in 
obliterating  them  altogether.  This  may  be  done  in  several 
ways.  Firm  and  continuous  pressure — a  suitable  piece  of  cork 
retuined  by  an  elastic  bandage — will  obliterate  the  vein;  or  a 
noose  of  silver  wire  may  be  passed  round  the  vein,  and  gradually 
tightened  till  it  cuts  its  way  out ;  but  perhaps  the  simplest  and 
best  method  is  to  pass  a  hare-lip  pin  under  the  vein,  and  then 
twist  a  thick  silk  firmly  over  it  in  the  form  of  a  figure-of-8. 
By  this  means  the  circulation  is  arrested,  a  coagulum  of  blood 
forms,  and  the  vein  is  closed  by  adhesive  inflammation.  As  many 
ligatures  of  this  kind  may  be  applied  as  the  case  requires.  Some 
surgeons  divide  the  vein  between  the  needles,  that  the  circula- 
tion through  it  may  not  afterwards  become  re-established.  But 
this  seems  to  be  an  unnecessary  proceeding,  and  one  which  is 
not  altogether  unattended  with  danger.  After  this  operation 
the  patient  should  wear  a  bandage  or  an  elastic  stocking,  to 
prevent  other  veins  from  becoming  varicose. 

INTlMA.Ji/liaA.TIO'N    OF    THE    I.irXVIPSATICS. 

The  lymphatics  are  liable  to  inflammation.  When  this  is  spon- 
taneous, it  is  generally  of  the  diff'use,  erysipelatous  kind.  But 
much  more  often  it  arises  from  the  irritation  of  a  scratch  or 
wound  in  an  unhealthy  subject.  The  lymphatics  become  red, 
tense,  and  swollen ;  while  the  lymphatic  glands  become  enlarged 
and  tender.  This  is  accompanied  with  a  good  deal  of  constitu- 
tional disturbance  and  prostration.  The  disease  often  leads  to 
erysipelas,  or  to  suppuration  in  the  affected  glands. 

The  treatment  should  include  purgatives  and  salines,  together 
with  a  strict  diet.  The  affected  limb  should  be  raised,  and  con- 
stantly fomented.     If  matter  forms,  it  should  be  let  out  at  once. 

Zia-FX.AIVIMATION-  OF  THE  IiYAZPHATZC 
GIiAITDS  (ABESTZTIS). 
The  lymphatic  glands  not  unfrequently  become  inflamed, 
without  apparent  inflammation  of  the  lymphatics  themselves. 
This  is  due  to  the  absorption  of  unhealthy  matter,  or  to  over- 
exertion, or  to  some  other  source  of  irritation.  In  young  persons 
of  a  strumous  habit,  it  is  common  to  see  the  glands  in  the  neck 
enlarged  in  consequence  of  carious  teeth,  or  a  sore  throat,  or 
an  eruption  on  the  scalp.  But  it  is  the  poison  of  syphilis  or 
gonorrhoea,  acting  upon  the  glands  in  the  groin,  which  supplies 
the  most  frequent  examples  of  adenitis. 


NEUEALGIA.  205 

The  inflammation  may  be  either  acute  or  chronic.  When  acute 
the  gland  becomes  rapidly  swollen ;  there  is  pain  and  tenderness, 
the  skin  is  red  and  hot,  and  suppuration  soon  takes  place. 
When  the  inflammation  is  of  a  more  chronic  kind,  the  gland 
enlarges  gradually  without  much  pain.  It  it  hard  and  callous 
to  the  touch,  and  if  suppuration  occurs  at  all,  it  is  long  delayed. 
The  chronic  enlargements,  which  are  so  common  in  strumous 
children,  probably  depend  upon  the  deposition  of  tuberculous 
matter  in  the  substance  of  the  gland. 

Treatment. — When  a  gland  is  acutely  inflamed  it  must  be 
treated  as  an  acute  abscess,  by  fomentations,  an  early  incision, 
and  poultices.  If  sinuses  remain,  they  will  require  to  be  dressed 
with  stimulating  lotions  (F.  12, 14,  25,  27),  and  kept  at  rest  by 
pads  and  bandages. 

When  the  inflammation  is  chronic  it  is  of  great  importance  to 
improve  the  general  health,  especially  where  there  is  a  strumous 
taint.  The  surgeon  should  inquire  into  the  climate  in  which 
his  patient  lives  and  the  hygienic  conditions  by  which  he  is  sur- 
rounded, such  as  the  situation  of  his  house,  the  drainage, 
the  water-supply,  &c.  A  residence  at  the  seaside  or  in 
a  dry  bracing  inland  climate,  with  plenty  of  fresh  air  and  sun- 
light, is  what  is  most  likely  to  suit  the  case.  Locally,  the 
disease  should  be  treated  w'ith  iodine  liniment,  or  with  the  oint- 
ment of  the  iodide  of  lead,  or  of  the  red  iodide  of  mercury. 
Extirpation  is  a  remedy  which  should  be  undertaken  with  very 
great  caution.  It  is  apt  to  lead  to  a  manifestation  of  the  disease 
elsewhere,  perhaps  in  some  more  vital  part,  such  as  the  lungs  or 
the  mesenteric  glands. 

CATO-CEH  of  the  IiVIVXPHATZC  GXiAXTDS. 

The  lymphatic  glands  are  sometimes  afiected  with  cancer. 
Primary  cancer  is  rare  in  this  situation,  and  is  generally  of  the 
epithelial  variety  ;  but  secondary  cancer  is  common,  especially  of 
the  meduUary  kind. 

Ifl-EVRAIiGIA 
is  an  acute  pain  specially  aflecting  the  nerves.  It  is  not  con- 
tinuous, but  intermittent.  The  paroxysms  vary  greatly  in 
severity,  and  in  duration.  The  pain  usually  makes  itself  felt  in 
the  same  situation,  following  the  course  of  some  large  nerve  or 
its  branches.  It  generally  affects  the  nerves  of  the  head, 
especially  the  divisions  of  the  fifth  pair.  It  is  also  met  with  in 
the  limbs  and  trunk,  and  sometimes  it  attacks  the  joints. 

The  causes  of  neuralgia  are  infinitely  various,  but  they  may 
all  be  summed  up  under  two  heads — (1)  local  irritation,  (2) 
defective  nutrition. 


206  DISEASES   OF  TISSUES  AND   ORGANS. 

Local  irritation  includes  carious  teeth,  spiculse  of  bone,  uterine 
disorder,  worms,  &c. 

Defective  nutrition  embraces  such  causes  as  anaemia,  chlorosis, 
malaria,  &c. 

The  diagnosis  must  be  established,  first,  by  a  careful  examina- 
tion of  the  whole  course  of  the  nerve,  to  see  whether  there  is 
any  local  cause  of  irritation ;  and,  secondly,  by  an  inquiry  into 
the  general  state  of  the  patient's  health. 

Treatment. — If  there  is  local  irritation,  we  must  endeavour  to 
remove  it.  If  it  is  the  general  health  which  is  at  fault,  we  must 
try  and  improve  it  by  appropriate  means.  A  change  of  air,  a 
more  generous  diet,  and  tepid  or  cold  sponging  are  often  of  great 
use.  At  the  same  time  some  of  the  preparations  of  iron  or  of 
quinine  should  be  prescribed  (F.  47,  65,  66). 

CONCVSSIOM'  OF  THE  BRAZST 

signifies  the  state  of  nervous  depression  which  is  produced  by  a 
sudden  blow  on  the  head.  This  blow  may  produce  a  shaken 
brain,  a  bruised  brain,  or  a  lacerated  brain  ;  accordingly  the 
degree  of  such  depression,  or  shock,  varies  extremely.  Some- 
times it  is  slight  and  transitory ;  at  other  times  it  is  deep  and 
prolonged.  Not  unfrequently  it  even  proves  fatal — either  imme- 
diately, by  arresting  the  action  of  the  heart  j  or  after  a  time,  by 
leading  to  its  gradual  failure  and  decline.  In  either  case,  the  fatal 
termination  takes  place  by  synco'pe,  death  beginning  at  the  heart. 

The  signs  of  a  severe  concussion  are  these  : — The  patient  lies 
motionless  and  insensible — he  is  stunned.  The  surface  of  the 
body  is  pale  and  cold ;  the  voluntary  muscles  and  sphincters  are 
relaxed ;  the  pulse  is  weak  and  intermittent ;  the  respiration  is 
slow  and  sighing ;  as  a  rule,  the  pupils  are  contracted,  but  some- 
times they  are  dilated,  and  occasionally  there  is  squinting. 

If  the  eyes  are  insensible  to  light,  and  if  the  legs  cannot  be 
excited  to  reflex  movements,  or  if  there  are  convulsions  (especially 
in  an  adult),  the  prognosis  is  unfavourable.  Vomiting,  on  the 
other  hand,  is  a  good  sign,  and  often  ushers  in  the  reaction. 

Concussion  of  the  brain  may,  as  we  have  said,  pass  off"  in  a  few 
minutes,  and  leave  no  trace  behind  it,  or  it  may  lead  to  the  speedy 
death  of  the  patient,  the  issue  depending  upon  the  amount  of 
injury  the  brain  has  sustained. 

But  between  these  two  extremes  there  are  other  eff'ects  which 
it  may  produce.  The  brain  may  be  permanently  injured,  the 
intellect  may  be  impaired,  or  the  patient  may  become  irritable 
and  excitable.  The  special  senses  may  become  blunted — there 
may  be  amaurosis,  or  deafness,  or  loss  of  smell,  or  stammering ; 
or  there  may  be  gradual  failure  of  muscular  power.     Cases  which 


COMPEESSION  OF  THE  BRAIN.  207 

follow  any  of  these  courses  are  apt  to  terminate  suddenly  from 
white  softening,  or  disintegration  of  the  brain  substance. 

The  treatment  of  concussion  of  the  brain  aims  (1)  at  restoring 
the  natural  functions,  and  (2)  at  preventing  the  reaction  from 
going  beyond  its  proper  limits. 

1.  The  patient  should  be  laid  in  bed,  well  wrapped  in  blankets, 
with  his  head  rather  low,  and  kept  perfectly  quiet.  A  hot-water 
bottle  should  be  applied  to  the  feet,  and  the  surface  of  the 
body  gently  rubbed.  No  alcoholic  stimulants  should  be  given, 
except  in  cases  of  great  depression. 

2.  When  reaction  has  began,  we  must  endeavour  to  keep  it 
from  running  on  to  inflammation.  With  this  view  the  patient 
should  be  confined  to  his  bed,  and  freely  purged.  He  should  be 
restricted  to  a  plain  diet,  and  all  sources  of  excitement  or  irrita- 
tion should  be  carefully  removed.  If  the  pulse  is  quick  and  the 
temperature  high,  cold  lotions  or  an  ice-bag  should  be  applied  to 
the  head ;  and  if,  in  a  robust  patieut,  the  symptoms  indicate 
encephalitis,  bleeding  and  antimony  should  be  employed  without 
delay. 

In  the  treatment  of  the  after-effects,  blisters,  issues,  setons, 
and  even  bloodletting  may  be  required. 

COMPRESSXOX  OF  THE  BRAIN 

may  arise  from  various  causes — e.g.,  from  depressed  bone,  from 
extravasated  blood,  from  the  exudation  of  lymph,  from  the 
lodgment  of  foreign  bodies,  from  the  formation  of  pus,  or  from 
morbid  growths. 

Signs. — The  patient  lies  in  a  state  of  stupor  and  insensibility ; 
sometimes  he  may  with  difficulty  be  aroused  to  answer  questions. 
The  skin  is  natural  in  colour,  warm,  and  moist.  The  pupils  are 
almost  always  dilated,  and  insensible  to  light ;  sometimes  they  are 
unequal.  The  pulse  is  slow  and  full.  The  face  is  often  flushed. 
The  breathing  is  regular  but  stertorous,  from  paralysis  of  the  velum 
palati,  and  the  cheeks  are  distended  at  each  expiration.  There 
is  more  or  less  paralysis  of  the  voluntary  mnscles;  sometimes  the 
sphincter  ani  is  similarly  affected,  giving  rise  to  involuntary  dis- 
charge of  faeces  ;  and  sometimes  the  bladder,  leading  to  engorge- ' 
ment,  and  overflow  of  urine.  There  is  also  a  tendency  to  death 
by  coma,  compression  of  the  medulla  oblongata,  and  cessation 
of  respiration  ;  death  beginning  at  the  lungs. 

In  speaking  of  concussion  and  compression,  it  is  necessary  to 
describe  typical  examples.  But  in  practice,  the  signs  are  often 
obscured,  or  the  two  states  are  merged  into  one  another,  and  they 
may  be  associated  with  fractures  of  the  skull. 

Treatment. — The  patient's  head  should  be  shaved.     If  frac- 


208  DISEASES  OF  TISSUES  AND  ORGANS. 

ture  exists,  it  must  be  dealt  with  according  to  the  rules  given 
elsewhere  (see  p.  134). 

If  there  is  no  fracture,  cold  should  be  continuously  applied,  and 
the  patient  should  be  freely  purged ;  one  or  two  drops  of  croton 
oil  may  conveniently  be  given  for  this  purpose. 

If  the  symptoms  get  worse,  and  death  is  imminent,  the  ques- 
tion of  trephining  may  be  considered.  But  it  is  often  so  difficult 
to  ascertain  the  exact  point  of  compression,  that  the  cases  in 
which  we  can  resort  to  the  trephine,  with  any  hope  of  success,  are 
extremely  rare. 

TRAUMATIC  EN-CEPBAIiZTZS 

signifies  inflammation  of  the  brain  or  its  membranes,  following 
injury  to  the  head.  It  presents  two  types,  w^hich  may  con- 
veniently be  called  the  acute  and  the  chronic  forms  of  the 
disease. 

In  the  acute  variety,  the  symptoms  come  on  early,  perhaps  in 
a  couple  of  days,  the  reaction  gradually  running  into  inflamma- 
tion. There  is  severe  pain  in  the  head,  with  nausea  and  vomit- 
ing, a  quick  and  full  pulse,  a  hot  and  flushed  skin,j:estlessness, 
iiritability,  and  intolerance  of  light ;  the  mind  is  wandering  and 
confused,  and  there  is  sometimes  violent  delirium.  When  sup- 
puration takes  place,  there  are  rigors,  followed  perhaps  by  the 
signs  of  laceration  and  compression,  such  as  squinting,  stertor, 
coma,  paralysis,  twitchings,  or  convulsions. 

The  treatment  should  be  antiphlogistic  and  sedative.  Ice  to 
the  scalp,  low  diet,  bleeding,  blisters,  purging  and  antimony 
(F.  38) — these  are  the  means  that  we  must  rely  upon.  As  a 
purge,  Bryant  recommends  calomel  in  butter,  to  be  followed  by  a 
turpentine  or  castor  oil  enema.  If  pus  has  formed,  and  its 
situation  can  be  discovered  with  any  certainty,  the  trephine  may 
be  used. 

In  the  chronic  variety  the  symptoms  do  not  make  their  appear- 
ance until  some  time,  perhaps  a  few  months,  after  the  injury.  It 
is  apt  to  follow  comparatively  slight  accidents,  from  which  the 
patient  thinks  that  he  has  completely  recovered.  There  is 
generally,  however,  some  symptom — loss  of  memory,  impairment 
of  the  senses,  irritability,  persistent  headache,  or  the  like — which 
indicates  a  permanent  alteration  in  the  brain-tissue.  Suddenly  an 
attack  of  inflammation  is  kindled,  which  runs  much  the  same 
course  as  in  the  acute  variety.  In  these  cases  there  is  probably 
a  chronic  inflammation  of  the  bone,  w^hich  gradually  extends  till 
it  reaches  the  dura  mater  and  the  brain. 

When  these  signs  of  a  permanent  alteration  in  the  substance 
of  the  brain  are  present,  the  patient  should  habitually  live  on  an 


CONTUSIONS   OF  THE  SCALP. 


209 


unstimulating  diet ;  he  should  take  an  occasional  purge,  and 
avoid  all  mental  or  hodily  excitement,  which  might  determine  an 
acute  inflammation.  If^  however,  such  an  attack  takes  place,  the 
early  treatment  should  be  active,  for  in  its  later  stages  the  case 
is  almost  hopeless. 


CONTUSXOXrS  OF  THS  SCAIiP 


Fig.  95. 


are  sometimes  followed  by  extravasation  of  blood,  either  beneath 
the  muscular  aponeurosis,  or 
beneath  the  pericranium  (cephal- 
hsematoma).  Such  collections  of 
blood  are  not  uncommon  in 
new-born  children,  apparently  as 
the  result  of  compression  of  the 
skull  during  parturition.  Fig.  95 
was  drawn  from  a  child  who 
was  born  in  Charing  Cross  Hos- 
pital. His  mother  had  been  ad- 
mitted on  account  of  a  transverse 
fracture  of  the  patella,  and  her 
leg  was  on  a  splint.  The  infant's 
head  did  not  touch  the  splint, 
but  the  position  was  an  awkward 
one  for  delivery.  At  the  end 
of  eight  months  the  tumour  had 
entirely  disappeared. 

When  the  centre  of  the  tumour  softens,  while  the  edges  remain 
hard,  it  is  very  apt  to  be  mistaken  for  a  depressed  fracture. 


Blood  tumour  of  the  scalp  : 
cephal  hsematoma. 


Treatment. — In  any  case,  the  ex- 
travasated  blood  should  be  left  to  itself, 
or  treated  only  with  an  evaporating 
lotion  (F.  18,  21) ;  an  incision  should 
never  be  made  to  let  it  out. 

Lotions,  or  other  applications  to  the 
scalp,  may  conveniently  be  kept  in 
position  by  a  simple  bandage,  such  as 
that  represented  in  Fig.  96.  The 
roller  is  first  carried  horizontally  round 
the  head,  then  pinned  at  the  temple, 
and  passed  over  the  vertex  in  any 
direction  that  the  case  may  require. 
If  necessary,  to  prevent  it  from  slip- 
ping, it  may  be  further  secured  by  a 
turn  under  the  chin. 


Fig.  96. 


Bandage  for  the  head. 


210 


DISEASES   OF  TISSUES  AND  ORGANS. 


SCAI.F  -WOUM-BS 

should  be  carefully  cleansed,  the  adjacent  hair  cut  away,  and  then 
their  edges  accurately  brought  together,  and  fixed  by  strips  of 
p.^  Q„  plaster,  or,  if  need   be,  by  silk, 

'^'      '  catgut,  or  wire  suture.    Provided 

that  the  needle  is  not  carried 
deeper  than  the  scalp,  there  is  no 
more  danger  in  using  sutures  in 
this  situation  than  in  any  other, 
but  the  aponeurosis  of  the 
occipito-frontalis  should  not  be 
pierced.  Haemorrhage  may  al- 
ways be  controlled  by  a  pad  and 
bandage.  It  is  an  axiom  in 
surgery  that  no  part  of  the  scalp 
ought  ever  to  be  removed,  no 
matter  how  much  it  may  be 
bruised,  or  how  slender  may  be  its 
attachments.  It  is  most  pro- 
bable that,  if  it  is  replaced,  it  will 
retain  its  vitality.  In  wounds 
of  the  scalp  there  is  always  more  or  less  danger  of  erysipelas,  or 
of  encephalitis.     The  patient  should  therefore  take  a  purge,  and 

restrict  himself  to  rather  a  low  diet 
for  a  few  days.  If  there  are  indi- 
cations of  suppuration  having  taken 
place  beneath  the  occipito-frontalis 
(phlegmonous  erysipelas),  an  incision 
should  be  made  at  once  quite  down 
to  the  bone,  and  poultices  or  dressings 
should  be  applied,  and  retained  by  a 
four-tailed  or  a  six-tailed  bandage. 

Four-tailed  handage  for  the  head. 
— This  bandage  consists  of  a  strip 
of  calico  a  yard  long  and  six  or  eight 
inches  broad,  which  is  slit  up  the 
middle  from  both  ends  to  within 
three  inches  of  the  centre.  In  this 
way  a  bandage  is  formed  which  has 
four  tails  of  equal  length  and  breadth, 
and  a  central  area  of  about  six  inches 
square.  This  central  portion  is  applied  to  the  vertex  in  the  re- 
quired position,  the  two  posterior  tails  are  then  brought  forward, 


Four-tailed  bandage. 


Fig.  98. 


Six-tailed  bandage. 


WOUNDS  OF  THE  BRAIN. 


211 


and  fastened  nnder  the  chin,  while  the  two  anterior  ones  are 
carried  back  below  the  occiput  and  tied ;  or  they  may  be  crossed 
in  this  situation,  brought  forward  round  the  neck  and  secured 
in  front  (Fig.  97). 

Sir-failed  bandage  for  the  head, — \Yhen  a  bandage  is  required 
which  will  cover  a  larger  part  of  the  head  than  the  four-tailed, 
we  have  recourse  to  the  sbi-tailed.  This  bandage  is  formed  of  a 
piece  of  calico  a  yard  long  and  eight  or  ten  inches  broad,  split 
from  each  end  into  three  tails  of  equal  breadth  to  within  three 
inches  of  the  centre.  The  central  portion  is  laid  upon  the  top  of 
the  head,  the  two  middle  tails  are  secured  underneath  the  chin, 
the  anterior  tails  are  carried  backwards  and  tied  at  the  nape  of 
the  neck,  and  then  the  posterior  ones  are  brought  forward  hori- 
zontally round  the  head,  and  fastened  over  the  brow  (Fig.  98). 

"WOTTxarDS  of  the  BRAmr 

arise  from  various  causes — depressed  fracture,  simple  unde- 
pressed fracture  or  concussion  with  lacei'ation,  penetrating  wounds, 
whether  punctured  or  incised,  &c. 

The  symptoms  are  those  of  concussion,  compression,  or  inflam- 
mation.    There  are  no  special  signs. 

It  makes  a  great  difference  -pis  99. 

what  part  of  the  brain  sub- 
stance is  injured.  If  it  is  any 
of  the  central  portions,  death 
takes  place  rapidly.  Children 
bear  wounds  of  the  brain 
better  than  adults  ;  and  those 
who  labour  with  their  hands 
better  than  those  who  work 
with  their  heads.  I  have 
already  alluded  to  a  remark- 
able case  which  occurred  in 
my  practice,  and  which  illus- 
trates these  points  (see  p.  136). 

Treatment.  —  The  case 
should  be  left  as  much  as 
possible  to  Nature.  If  a 
foreign  body  is  present  in  the 
wound  it  should  be  gently 
and  cautiously  removed.  The 
general  treatment  should  be 
antiphlogistic.  The  dressings  should  be  of  the  simplest  kind — 
e.g.,  lint  dipped  in  cold  water.  Slight  and  equable  pressure 
should  be  maintained  over  the  wound,  to  prevent  protrusion  of 

p  2 


Capitellum  bandage  (1). 


212 


DISEASES  OF  TISSUES  AND  OEGANS. 


the  substance  of  the  brain  (hernia  cerebri).     For  this  purpose 
the  capitellum  bandage  will  sometimes  be  found  useful. 

The  capitellum,  or  complete  bandage  for  the  head,  requires  a 
long  double-headed  roller,  rather  narrower  than  an  arm-bandage. 
In  practice  it  is  found  a  convenient  method  to  stitch  two 
single-headed  rollers  together,  and  thus  to  form  a  long  double- 
headed  one. 

The  operator,  standing  behind  his  patient,  places  the  centre  of 
the  bandage  on  the  forehead,  and  conducts  the  rollers  horizon- 
tally round  the  head,  one  to  the  right  and  the  other  to  the  left, 
as  far  as  the  occiput,  that  in  the  right  hand  being  passed  under- 
neath the  left  and  lying  next  the  head.  Care  should  be  taken 
to  place  the  bandage  low  down,  both  on  the  brow  and  on  the 
occiput,  so  that  it  may  get  a  good  hold,  and  be  prevented  from 
slipping  upwards.  On  reaching  the  occiput  the  bandage  in  the 
right  hand  is  transferred  to  the  left,  and  that  in  the  left  is  trans- 
ferred to  the  right.  The  bandage  in  the  right  hand  is  now 
pressed  firmly  against  the  head,  and  kept  in  that  position  so  as  to 
fix  the  under  one ;  while  that  in  the  left  is  taken  straight  over 
the  vertex  to  the  brow  in  the  median  line  (Fig.  99).  The 
right-hand  bandage  is  now  continued  horizontally  round  the  head 
over  the  right  ear,  until  it  arrives  at  the  brow,  where  it  meets 
the  bandage  in  the  left  hand,  and  crosses  in  front  of  it.  The 
rollers  must  now  change  hands  again  ;  that  in  the  left  hand,  the 
horizontal  one,  is  pressed  firmly  against  the  head,  whilst  that  in 
the  right  is  brought  over  the  vertex,  from  before  backwards,  as 
-p.     ^QQ  far     as     the     occiput, 

^'       *  slightly  overlapping  the 

first  fold  (Pig.  100), 
starting  from  the  front 
a  little  to  the  right, 
and  finishing  at  the 
occiput,  a  little  to  the 
same  side  of  the  median 
line.  By  arranging  in 
this  way  the  two  folds, 
which  are  placed  on 
either  side  of  the  central 
one,  we  are  enabled  to 
make  them  lie  flat,  and 
to  adapt  them  to  the 
shape  of  the  head.  The 
bandage  in  the  left 
hand  is  now  carried  on  horizontally  round  the  head,  over  the 
left  ear,  to  the  occiput,  where  it  passes  over  that  in  the  right 


Capitellum  bandage  (2). 


SPINA  BIFIDA.  213 

hand.  The  bandages  are  now  made  to  change  hands  again ; 
that  in  the  right  hand,  the  horizontal  one,  is  firmly  pressed 
against  the  head,  whilst  that  in  the  left  is  taken  over  the  vertex 
from  behind  forwards,  as  before.  The  bandage  in  the  right  hand 
is  again  carried  round  the  head,  over  the  right  ear,  as  far  as  the 
forehead,  in  front  of  that  in  the  left  hand.  The  bandages  are 
now  again  transferred  from  hand  to  hand  ;  and  that  in  the  left 
hand  is  pressed  firmly  against  the  head,  while  that  in  the  right  is 
conducted  directly  over  the  head,  from  the  brow  to  the  occiput,  a 
little  to  the  side  of  the  previous  fold.  These  steps  are  repeated  as 
often  as  they  are  necessary,  until  the  whole  head  has  been  covered  ; 
and  then  the  bandages  are  carried  once  horizontally  round  the 
head,  or  fastened  with  pins,  or  tied  in  a  knot. 

SPINA  BIFIDA 

is  the  name  given  to  a  congenital  malformation,  wherein  the 
spinous  processes  of  the  vertebrse  are  deficient,  and  the  laminae 
are  open.  The  consequence  is  that  the  coverings  of  the  cord 
yield  to  the  pressure  of  the  cerebro-spinal  fluid,  and  a  tumour  is 
formed. 

Spina  bifida  is  generally  met  with  at  the  lower  part  of  the 
spine,  in  the  lumber  and  sacral  vertebra3. 

The  tumour  which  is  formed  is  in  the  mesial  line,  fluctuating, 
highly  elastic  when  the  patient  is  erect,  but  when  he  lies  down  it 
becomes  soft  and  lax.  It  is  usually  about  the  size  of  an  orange. 
Sometimes  the  skin  is  unaffected  ;  at  other  times  it  is  congested 
and  blue ;  and  not  unfrequently  a  nsevus  is  situated  on  it. 

If  left  to  itself  it  may  ulcerate  and  burst,  and  then  it  is  pro- 
bable the  patient  will  die  of  inflammation  of  the  cord  and  its 
coverings ;  or  it  may  give  little  or  no  annoyance,  and  the  patient 
may  grow  up  to  adult  life.  But,  iu  the  great  majority  of 
instances,  the  patients  die  at  an  early  age  from  convulsions,  or 
paralysis,  or  from  some  other  like  cause. 

The  treatment  is  either  palliative  or  curative.  The  tumour 
should  always  be  protected  by  cotton  wool  and  by  a  leather  or 
felt  case,  moulded  so  as  to  fit  it  exactly  and  exercise  equable 
pressure  upon  it.  If,  notwithstanding,  the  disease  goes  on 
increasing,  the  sac  may  be  punctured  with  a  fine  trochar, 
part  of  the  contents  let  out,  and  pressure  applied  as  before. 
This  proceeding  may  be  repeated  from  time  to  time,  as  the  case 
requires.  Dr.  J.  Morton,  of  Glasgow,  recommends  tapping  the 
tumour,  and  injecting  it  with  a  solution  of  iodine  in  glycerine. 
Cures  have  occasionally  been  effected  by  many  different  modes  of 
treatment,  but,  on  the  whole,  the  prognosis  is  unfavourable,  and 
the  result  of  curative  measures  unsatisfactory. 


214  DISEASES  OF  TISSUES  AND  OEGANS. 


ZiATERAXi  CURVATURE  OF  THE  SPINE 

frequently  occurs  in  young  persons,  especially  in  girls  about  the 
age  of  puberty.  It  sometimes  depends  upon  rickets,  b\it  more 
frequently  upon  weakness  and  relaxation  of  the  muscles  and 
ligaments  of  the  spine.  The  primary  curve  generally  takes  place 
in  the  dorsal  region,  and,  if  the  disease  advances,  a  second,  or 
compensatory  curve,  usually  manifests  itself  lower  down,  in  the 
lumbar  region. 

Signs. — One  shoulder  is  higher  than  the  other.  The  corre- 
sponding side  of  the  chest  or  back  projects,  the  scapula  "  grows 
out."  The  pelvis  is  tilted  in  the  opposite  direction.  On  examina- 
tion it  is  found  that  the  spine  is  curved ;  and,  if  the  case  is  a 
bad  one,  the  curve  will  be  double,  like  the  letter  S. 

Causes. — The  predisposing  cause  is  muscular  debility.  This  is 
generally  associated  with  an  ausemic  or  bilious  state  of  the  health, 
at  a  time  when  the  patient  is  growing  rapidly.  Lateral  curvature 
is  more  common  among  the  upper  classes,  who  lead  a  luxurious 
life,  than  among  those  who  have  to  work  and  who  exercise  their 
muscles  regularly. 

The  immediate  cause  is  the  excessive  employment  of  one  side 
of  the  body — as  in  standing  on  one  leg,  using  one  arm  in  needle- 
work, writing,  &c. 

The  intervertebral  cartillages  are  unequally  compressed,  and, 
if  this  goes  on  continuously  for  a  length  of  time,  they  do  not 
recover  themselves.  A  permanent  alteration  takes  place  in  the 
outhne  of  the  spine,  a  slight  curve  is  established,  and  to  this  the 
muscles  and  ligaments  soon  adapt  themselves. 

Treatment. — The  first  thing  is  to  improve  the  general  health 
by  a  careful,  but  nutritious,  diet,  by  moderate  exercise  in  the 
open  air,  and  by  tonic  and  alterative  medicines. 

The  next  object  is  to  brace  the  relaxed  muscles  and  ligaments 
of  the  spine.  This  may  be  done  by  cold  sponging  and  friction. 
The  back  may  be  sponged  every  morning,  and  rubbed  with  a 
stimulating  liniment  every  night — e.g.,  the  lin.  ammonise,  or  the 
lin.  sinapis,  or  the  lin.  camph.  co. 

The  third  indication  is  to  relieve  the  spine  of  the  weight  which 
it  has  to  support.  With  this  view,  the  patient  should  not  be 
allowed  to  stand  or  sit  much.  Once  or  twice  during  the  day  she 
should  lie  down  on  a  flat  sofa  for  an  hour,  either  in  the  prone 
position  or  the  supine. 

If  there  is  much  deformity  when  the  case  is  first  seen,  or  if  it 
continues  to  make  progress,  notwithstanding  the  employment  of 


ANGULAR  CURVATURE  OF  THE  SPINE.        215 


the  means  we  have  mentioned,  the  patient  should  be  treated  by 
means  of  Sayre's  plastei*  jacket,  or  should  wear  a  mechanical 
contrivance,  to  take  the  weight  of  the  body  off  the  spine,  and  to 
press  the  outgrowing  part  into  its  proper  position. 

A  well-devised  course  of  gymnastics  may  be  of  great  use,  not 
only  in  improving  the  condition  of  the  muscles  and  ligaments, 
but  also  in  counteracting  any  deformity  which  may  have  already 
arisen. 

AM-GUZ.AR  CURVATURE  OF   THE  SPINE 

is  a  disease  of  strumous  origin,  and,  like  the  other  manifesta- 
tions of  scrofula,  it  is  more  common  in  early  than  in  adult 
life. 

Inflammation  takes  place  in  the  bodies  of  the  vetebrse — 
perhaps  as  a  consequence  of  the  deposit  of  tubercle — the  can- 
cellous tissue  softens  and  breaks  down,  giving  rise  internally 
to  abscess,  and  externally  to  an  angular  projection  of  the  spine. 
The  mid- dorsal  region  is  that  which  is  most  apt  to  be  affected  : 
sometimes  as  many  as  five  or  -c^-     -n 

six  vertebrae,  with  their  inter-  ^^' 

vertebral  discs,  are  involved  in 
the  disease.  The  measure  of 
the  angle  will  depend  in  each 
case  upon  the  number  of  ver- 
tebrae which  are  implicated,  and 
upon  the  extent  to  which  the 
morbid  action  has  advanced. 
In  slight  cases,  the  projection  is 
hardly  noticeable ;  in  severe 
cases,  it  is  sharp  and  prominent, 
as  in  Fig.  iOl,  which  was 
drawn  from  a  preparation  in 
Charing  Cross  Hospital 
Museum. 

Signs. — Weakness  of  the 
back,  with  slight  local  pain, 
which  is  aggravated  on  pres- 
sure. Perhaps  the  spines  of 
the  vertebrae  are  more  promi- 
nent than  they  should  be. 
These  symptoms,  coupled  with  the  general  indications  of  scrofula, 
are  all  that  we  have  to  enable  us  to  form  an  early  diagnosis ; 
and  such  a  diagnosis  is  here  of  great  importance. 

When  the  disease  has  advanced  further,  there  may  be  twitchings 
of  the  limbs,  or  partial  paralysis  j  the  pain  is  then  more  acute. 


Angular  curvatm^e  of  the  spine. 


216  DISEASES   OF  TISSUES  AND   OEGANS. 

particularly  when  the  spine  receives  a  smart  blow,  or  is  rudely 
shaken;  and  the  deformity  is  greater. 

When  cases  are  submitted  to  treatment  in  the  early  stage,  the 
destructive  process  may  be  arrested,  the  disintegrated  tissue  may 
be  absorbed,  ankylosis  may  take  place  between  the  bodies  of  the 
vertebrae,  and  nothing  may  remain  but  a  slight  projection  of  the 
spine. 

In  more  severe  cases,  it  is  probable  that  an  abscess  will  form 
(lumbar,  psoas,  or  iliac  abscess).  If  this  happens,  the  patient  is 
very  likely  to  sink  from  exhaustion  and  hectic ;  or  he  may  die, 
at  a  much  earlier  stage  of  the  disease,  by  implication  of  the  spinal 
cord. 

Sometimes  the  disease  affects  the  cervical  vertebrae,  and  then 
abscess  may  form  and  point  either  in  the  pharynx,  or  at  the  side 
of  the  neck,  under  the  sterno-mastoid  muscle.  When  the  atlas 
and  axis  are  diseased,  the  symptoms  are  very  urgent,  and  the 
aspect  of  the  patient  characteristic.  He  is  afraid  to  bend  his 
neck  or  turn  his  head,  so  he  keeps  it  stiff.  When  he  turns,  he 
turns  his  whole  body.  Sometimes  he  even  supports  his  head 
with  his  hands — Nature  teaching  him  that  it  must  be  kept  at 
rest.  The  best  hope  of  a  cure  lies  in  keeping  the  bones  perfectly 
at  rest  by  means  of  some  apparatus.  If  dislocation  takes  place, 
the  cord  may  be  compressed,  and  sudden  death  may  be  the 
result. 

Treatment. — The  main  points  are  to  take  the  weight  off  the 
spine,  and  to  keep  the  vertebrae  at  rest,  in  a  favourable  position 
for  repair  and  union. 

A  few  years  ago.  Dr.  Sayre,  of  New  York,  introduced  a  great 
improvement  into  the  treatment  of  curved  spines.  His  method 
is  applicable  both  to  angular  curvature  and  to  the  more  severe 
cases  of  lateral  curvature.  The  surgeon  should  provide  him- 
self with  a  bandage  of  coarse  muslin — "crinoline  muslin"  as  it 
is  called.  It  should  be  four  inches  wide  and  about  twelve  yards 
long.  Into  both  sides  of  it  the  dry  plaster  of  Paris  should  be 
rubbed,  and  then  it  should  be  loosely  rolled.  When  it  is  re- 
quired for  use,  it  should  be  immersed  in  water  for  about  a 
minute.  The  patient  should  wear  an  ordinary  close-fitting  vest. 
Supports  are  placed  under  his  armpits,  as  well  as  under  his  chin 
and  occiput,  and  by  these  he  is  carefully  suspended  under  a 
tripod,  and  slowly  raised  until  he  touches  the  ground  only  with 
his  toes.  Thus  the  weight  of  the  body  is  used  as  an  extending 
force  to  uncurve  and  straighten  the  spine.  There  is  no  danger 
in  this  operation,  if  it  is  properly  performed,  even  in  severe  and 
acute  cases.  When  the  patient  is  suspended,  the  plaster  of  Paris 
bandage  is  rapidly  appHed  from  the  pelvis  to  the  axillae,  care 


ANGULAE  CUEVATUEE  OF  THE  SPINE.         217 

being  taken  to  put  a  pad  of  cotton-wool  wherever  it  may  be 
needful.  If  slips  of  tin  or  of  whalebone  are  introduced  in  a  ver- 
tical direction  between  the  layers  of  the  bandage  as  it  is  being 
applied,  they  add  much  to  its  strength  and  firmness.  In  a  few 
minutes  the  plaster  of  Paris  sets,  and  forms  an  unyielding  jacket. 
The  patient  should  then  be  carefully  lowered  from  the  tripod, 
and  laid  on  his  back  on  a  sofa  for  a  short  time.  As  soon  as  he 
has  become  accustomed  to  his  new  splint,  he  may  be  allowed  to 
walk  about ;  for,  in  truth,  the  jacket  is  to  be  regarded  as  a  splint 
for  the  now  extended  spinal  column.  Various  substances  have 
been  tried  in  the  hope  of  finding  something  more  convenient  than 
plaster  of  Paris;  but  nothing  answers  the  purpose  unless  it 
gives  a  firm  and  solid  support.  The  comfort  and  benefit  which 
patients  derive  from  Sayre's  method  of  treatment  are  immediate 
and  striking.  There  are  only  two  classes  of  cases  to  which  it  is 
inapplicable — namely,  those  who  are  confirmed  cripples,  and 
those  who  are  sinking  under  disease.  The  presence  of  an 
abscess  need  not  interfere  with  the  adoption  of  this  treat- 
ment. 

If  the  curvature  is  in  the  upper  dorsal  or  cervical  vertebrae,  a 
"jury-mast"  should  be  attached  to  the  jacket,  and  by  this  the 
head  should  be  supported. 

Great  care  must  be  taken  that  the  jacket  does  not  chafe  or  gall 
the  patient.  If  it  is  comfortable,  it  may  be  worn  for  a  month 
or  longer;  then  cut  off";  the  skin  well  washed,  and  a  fresh  jacket 
applied  in  the  same  way  as  before. 

Dr.  T.  J.  Walker,  of  Peterborough,  recommends  that  the 
plaster  bandage  should  be  applied  while  the  patient  lies  flat  on 
a  couch.  This  method  has  its  advantages;  but  it  may  be 
doubted  whether  it  is  so  effectual  as  that  by  suspension. 

Cooking's  poro-plastic  jackets,  and  other  similar  appliances 
made  of  felt,  are  convenient,  and  may  sometimes  be  used  with 
advantage;  but  they  lack  the  solidity  of  the  plaster  jackets; 
and  moreover  the  patient  can  unfasten  them,  which  is  a  great 
drawback. 

In  slight  cases  it  may  be  enough  to  use  a  felt  jacket,  and  to 
desire  the  patient  to  maintain  the  horizontal  position  during  a 
great  part  of  the  day.  A  mechanical  couch,  such  as  Alderman's, 
will  be  found  very  convenient  for  the  purpose. 

It  is  scarcely  necessary  to  add  that  everything  must  be  done 
to  improve  the  general  health  by  fresh  air,  a  careful,  but  nutri- 
trious,  diet,  and  tonic  and  alterative  medicines.  In  cases  that 
are  seen  early,  we  must  try  to  bring  about  a  more  healthy  local 
action  by  counter-irritation  with  iodine,  blisters,  issues,  &c. 


218 


DISEASES   OF  TISSUES  AND  OEGANS. 


I.UMBAR,  FSOAS,  ANH  ZX.ZAC  ABSCESS. 

When  the  tubercular  matter  softens,  and  the  cancellous  tissue 

breaks  down,  it  often  gives  rise,  as  we  have  said,  to  abscesses.     Such 

^  --  abscesses  attain  agreatsize, and 

°'       *  extend  in  various  directions, 

according  to  the  situation  of 

the  disease. 

Sometimes  they  make  their 
way  among  the  muscles  of  the 
back,  and  point  in  the  loins 
(luTnbar  a).  Sometimes  they 
travel  down  the  spine,  under 
the  pillars  of  the  diaphragm, 
along  the  course  of  the  aorta 
and  external  iliac  artery  and 
point  above  Poupart's  liga- 
ment {iliac  a).  An  abscess 
which  presents  itself  in  this 
situation  is  generally  con- 
nected with  disease  in  the 
upper  dorsal  region.  When 
the  disease  is  rather  lower 
down,  in  the  lower  dorsal  or  lumbar  vertebrae,  the  abscess  is  guided 
by  the  sheath  of  the  psoas  muscle,  and  points  on  the  inside  of  the 
thigh,  below  Poupart's  ligament  (psoas  a).  Fig.  102  was  drawn 
from  a  patient  who  was  in  Charing  Cross  Hospital,  under  the  care  of 
Mr.  Canton,  and  who  died  of  a  double  psoas  abscess,  connected 
with  disease  of  the  lower  dorsal  vertebrae. 

Abscesses  originating  in  disease  of  the  spine  may  present 
themselves  in  various  other  situations — for  example,  in  the  pharynx, 
in  the  neck,  in  the  front  of  the  abdomen,  or  in  the  perineum. 
In  each  case,  these  abscesses  will  have  to  be  distinguished  from 
other  collections  of  pus,  arising  independently  of  spinal  disease. 

Treatment. — When  the  abscess  distinctly  points,  it  may  be 
opened  by  a  small  valvular  incision,  part  of  the  contents  let  out, 
and  the  opening  closed  again.  This  may  be  done  from  time  to 
time,  as  often  as  occasion  requires.  Until  the  abscess  begins  to 
involve  the  skin,  and  threatens  to  ulcerate,  it  should  not  be  opened : 
the  surgeon  should  content  himself  with  ordering  perfect  rest, 
and  improving  the  general  health.  If  free  suppuration  and  dis- 
charge once  begin,  fatal  hectic  is  likely  to  be  the  result.  On  the 
other  hand,  every  surgeon  has  seen  cases  in  which  large  collections 
of  pus  have  gradually  become  absorbed,  as  the  patient's  health 


Double  psoas  abscess. 


FRACTUEE  OF  THE  SPINE.  219 

improved.  Drawing  off  tbe  pus  by  means  of  the  aspirator  may  be 
beneficial  in  some  instances.  If  it  is  deemed  necessary  or  desirable 
to  open  tbe  abscess,  tbis  sliould  be  done  by  Lister's  metbod.  Pre- 
paration should  be  made  for  tbe  thorough  application  of  antiseptic 
principles,  and  then  the  abscess  should  be  freely  opened  (see  p.  15). 

XN-JURIES  OF  THE  SPIM-AIi  CORD. 

The  spinal  cord,  like  the  brain,  is  liable  to  be  concussed,  com- 
pressed, or  ivounded.  The  vertebrse  are  sometimes  dislocated. 
Of  late  years  much  attention  has  been  devoted  to  these  injuries, 
both  to  their  immediate  and  their  remote  effects,  in  consequence 
of  the  frequent  litigation  arising  out  of  railway  accidents.  When 
the  cord  is  concussed,  there  may  be  loss  of  nerve-power  from  the 
mere  shock.  When  there  is  compression,  laceration,  or  disloca- 
tion, there  may  be  immediate  loss  of  nervous  functions  and  sub- 
sequent inflammation.  The  more  severe  injuries  are  often  asso- 
ciated with  fracture. 

FRACTURE  OF  THE  SPIITE 

may  arise  from  direct  violence,  or  from  the  spine  being  bent  until 
it  breaks — as,  for  example,  in  the  act  of  falling. 

The  symptoms  are  partly  local,  such  as  belong  to  all  fractures, 
and  partly  nervous,  depending  upon  the  nature  and  amount  of 
injury  which  the  cord  has  sustained. 

The  local  symptoms  are  pain,  loss  of  power,  and  an  irregularity 
of  the  spine.  Sometimes  tbe  spinous  processes  are  unnaturally 
far  apart,  with  a  gap  between  them ;  sometimes  one  portion  of 
the  column  is  prominent,  while  another  is  depressed. 

If  the  cord  is  so  far  compressed,  or  lacerated,  that  its  functions 
are  arrested,  there  will  be  loss  of  both  motion  and  sensation 
below  the  point  of  injury.  If  the  fracture  is  situated  in  the  lum- 
bar region,  the  lower  part  of  the  trunk,  the  genito-urinary 
organs,  and  the  lower  limbs  will  be  paralysed,  while  the  upper 
part  of  the  body  remains  unaffected.  In  this  state  the  patient 
may  live  for  a  few  months ;  death  taking  place  from  exhaustion, 
consequent  upon  sloughing  of  tbe  nates,  or  disease  of  the  bladder, 
or  an  intercurrent  inflammation. 

If  the  injury  is  in  the  upper  dorsal  region,  the  intercostal  muscles 
will  be  paralysed  as  well,  and  breathing  will  be  carried  on  entirely 
by  the  diaphragm.  Under  these  circumstances,  the  patient  may 
perhaps  live  a  week,  dying  ultimately  with  congestion  of  the  lungs. 

If  tbe  fracture  traverses  the  lower  cervical  vertebrae,  the  upper 
extremity  will  share  in  the  paralysis. 

In  all  these  cases  the  intellect  remains  clear  and  unaffected. 


220  DISEASES  OF  TISSUES  AND  OEGANS. 

If  the  lesion  is  a  little  higher  up,  above  the  origin  of  the 
phrenic  nerve,  death  takes  place  instantly  from  cessation  of 
respiration. 

Treatment. — When  the  fracture  is  in  the  lower  dorsal  or  lumbar 
region,  the  patient's  life  may  be  prolonged,  and  much  may 
be  done  to  make  it  more  tolerable.  With  this  view,  he  should 
be  laid  on  a  water-bed,  and  kept  perfectly  clean.  Everything 
should  be  done  to  prevent  sloughing  of  the  nates.  An  occasional 
purgative  or  enema  should  be  given.  As  the  urine  is  apt  to 
become  offensive  and  ammoniacal,  it  should  be  drawn  off,  and 
the  bladder  washed  out  twice  a  day  j  at  the  same  time,  perfect 
quietness  and  repose  should  be  enforced. 

When  the  injury  is  higher  up,  little  can  be  done  in  the  way 
of  alleviation. 

In  rare  cases  fracture  may  occur  without  serious  consequences. 
The  spinous  processes  alone  may  be  broken  off;  or  the  cord  may 
escape  uninjured,  even  though  the  fissure  traverses  the  laminse, 
or  the  bodies  of  the  vertebrse. 

SAIiIVART  FZSTUIiA. 

Occasionally  the  duct  of  the  parotid  gland  (Steno's  duct) 
is  wounded ;  or  an  abscess  forms  in  its  track,  and  bursts 
externally.  In  either  case,  a  salivary  fistula  is  likely  to  be  the 
result.  The  secretion  from  the  parotid,  instead  of  making  its 
way  into  the  mouth,  dribbles  over  the  cheek. 

The  treatment  consists  in  establishing  an  opening  into  the 
mouth  by  means  of  a  few  threads  of  silk,  or  a  wire,  or  a  piece  of 
catgut,  passed  from  without  inwards,  in  the  line  of  the  duct,  and 
tied  in  a  loop  through  the  mouth.  The  next  point  is  to  close 
the  skin  of  the  cheek  over  the  fistulous  opening.  This  may  be 
done  by  touching  the  edges  with  nitrate  of  silver  or  with  the 
actual  cautery  so  as  to  make  them  contract ;  or  by  paring  the 
edges,  and  bringing  them  accurately  together ;  or  by  dissecting 
the  skin  around  the  wound,  and  sliding  it  along  so  as  to  cover 
the  opening.  But,  under  any  circumstances,  salivary  fistula  is  a 
diflBcult  thing  to  cure. 

HARE-XiZP 

signifies  a  congenital  fissure,  or  fissures,  in  the  upper  lip.  It  is 
often  associated  with  malformation  of  the  superior  maxillary,  or 
inter-maxillary,  bones — especially  with  cleft  palate.  When  the 
fissure  occurs  on  one  side  only,  it  is  said  to  be  single,  when  on 
both  sides  double  (Fig.  103).  When  there  is  but  one  fissure,  it  is 
generally  on  the  left  side. 


HAEE-LIP. 


221 


Fig.  103. 


The  treatment  of  an  ordinary  case  of  single  harelip  is  simple 
enough.  It  consists  in  dissecting  the  lip  from  the  adjacent  bone, 
paring  the  edges  of  the  fissure,  bringing  them  accurately  together, 
and  securing  them  by  means  of 
hare-lip  pins,  over  which  a  thick 
silk  is  twisted  in  the  form  of  a  figure- 
of-8.  The  wound  and  the  sutures 
should  then  be  freely  painted  with 
collodion,  to  exclude  the  air,  and  pro- 
mote union  by  adhesion.  The  spring 
compressor,  devised  by  Mr.  Hainsby, 
is  a  great  assistance.  It  consists 
of  a  horse  shoe  spring,  which  passes 
horizontally  round  the  back  of 
the  head,  on  a  level  .  with  the 
upper  lip,  and  which  is  supported  by  straps  going  over  the 
vertex  and  occiput  (Fig.  104).  The  spring  is  covered  throughout 
with  leather,  and  at  each  end  it  is  furnished  with  small  soft 


Double  hare-lip. 


Fig.  104. 


Hainsby's  spring 
compressor. 


pads,  which  bear  upon  the  cheeks,  pushing 
the  two  sides  of  the  lip  together,  and  thus 
preventing  tension.  After  the  lapse  of  three 
or  four  days  the  pins  may  be  withdrawn, 
and  the  scab  allowed  to  fall  off. 

When  the  fissure  is  double,  both  sides  may 
be  operated  on  in  a  similar  way  either  at 
the  same  time,  or  at  an  interval  of  a  fort- 
night. The  latter  is  probably  the  better 
plan. 

When  the  case  is  complicated  with  mal- 
formation of  the  bones,  or  protrusion,  the  surgeon  will  have  to 
exercise  his  ingenuity  in  planning  the  operation. 

The  time  at  which  the  operation  ought  to  be  performed  is  an 
important  question.  It  is  now  pretty  well  settled  that  it  should 
be  done  at  an  early  age — say  at  three  months — unless  special 
circumstances  require  delay.  "  From  all  my  reflections  and  ex- 
perience on  the  question,"  says  Sir  William  Fergusson,  "  T  am 
more  than  ever  disposed  to  recommend  a  very  early  operation. 
Most  of  my  patients  have  been  under  three  months  (some  of 
them  only  8  and  10  days)  old,  and  these  cases,  as  well  as 
experience  derived  from  other  sources,  induce  me  to  recommend 
the  earliest  reasonable  date  in  all  instances  of  the  kind,  unless 
there  be  some  apparent  indication  not  to  interfere.  I  have 
frequently  observed  that  the  younger  the  infant  the  more  satis- 
factory was  the  union  within  the  first  few  days." 


222  DISEASES   OF  TISSUES  AND  ORGANS. 


EPZTHEILIOMA  OF  THE  I.IP 

is  a  common  disease,  and  one  which  is  much  more  often  seen  in 
men  than  in  women.  It  commences  as  a  tubercle  or  a  fissure, 
and  may  often  be  traced  to  some  local  irritation — for  example,  to 
the  habitual  use  of  a  short  clay  pipe.  The  disease  may  remain 
for  a  long  time  in  a  state  of   abeyance;  then,  suddenly,  the 

growth    begins    to    en- 
^^'      ^'  large,   becomes   painful, 

and  ulcerates.  A  foul 
and  offensive  sore,  with 
an  indurated  base,  pre- 
sents itself.  Gradually 
it  spreads,  until  it  in- 
volves the  whole  lip. 
The  glands  underneath 
the  jaw  become  en- 
larged, and  the  patient 
at  length  dies,  worn  out 
by  the  pain  and  irri- 
tation. Fig.  105  was 
drawn  from  an  old 
woman  who  was  a 
patient  in  Charing  Cross 
Hospital.  She  had 
been  in  the  habit 
of  smoking  for  thirty 
Epithelioma  of  the  lower  lip.  years.    Dr.  Elmslie  men- 

tions that  the  Kashmiris 
are,  in  a  similar  manner,  subject  to  epithelial  cancers  on  the  thighs 
and  other  parts  from  the  practice  which  they  adopt  in  cold 
weather  of  carrying  a  brazier  next  the  skin,  under  the  flowing 
garment  which  forms  their  only  covering. 

The  treatment  consists  in  early  and  free  excision.  If  the 
disease  is  limited,  a  V-shaped  incision  may  be  sufficient  to  include 
it  all.  But,  if  it  is  more  extensive,  it  will  have  to  be  removed 
by  a  semicircular  cut.  In  any  case,  it  is  but  too  probable  that 
the  disease  will  reappear  in  the  course  of  a  few  months  or 
years. 

X.UPUS 

is  the  common  name  which  is  given  to  certain  obstinate  and 
intractable  ulcers  which  sometimes  attack  the  face.  There  are 
two  varieties  of  lupus — 1, 1,  non-exedens ;  and  2, 1,  exedens. 


LUPUS.  223 

1.  Lupus  non-exedens  (serpiginous  ulceration  of  the  face)  is 
essentially  a  scrofulous  disease.  It  usually  begins  on  one 
ala  of  the  nose,  as  a  red,  raised  tubercle,  which  ulcerates 
and  spreads.  It  only  affects  the  surface  of  the  true  skin,  and 
never  reaches  the  subcutaneous  tissue.  It  may  extend  over  a 
great  part  of  the  fiice — healing  in  one  direction,  while  it  goes  on 
spreading  in  another.  The  ulcerative  process  goes  on  merely  at  the 
margins.  The  cicatrix  which  is  left  behind  is  hard  and  puckered; 
sometimes  it  is  white  and  shining ;  sometimes  red,  congested,  and 
irritable. 

Tubercular  lupus  is  a  disease  which  is  particularly  apt  to  affect 
young  persons.  It  often  gives  rise  to  great  deformity,  com- 
pressing the  nose,  laying  open  its  cavity,  or  drawing  down  the 
eyelids. 

The  treatment  consists  in  soothing  the  local  disease  while  we 
endeavour  to  improve  the  general  health.  The  patient  should  be 
instructed  to  wear  a  veil,  and  avoid  exposure  to  wind  and  dust. 
Lint  spread  with  a  simple  ointment,  or  a  glycerine  lotion, 
should  be  applied  to  soften  the  skin,  and  exclude  the  air.  If 
the  disease  is  spreading  rapidly,  the  line  of  ulceration  may  be 
touched  with  nitric  acid,  or  with  the  actual  cautery.  The 
patient  should  live  on  a  plain  but  nutritious  diet,  and  take 
arsenic,  or  cod-liver  oil,  or  the  preparations  of  iron,  or  quinine 
(F.  47,  65). 

There  is  a  serpiginous  ulceration  of  the  face  which  is  of 
syphilitic  origin,  and  which  needs  to  be  distinguished  from  the 
above,  because  it  requires  specific  treatment. 

2.  Lupus  exedens  (rodent  ulcer  or  cancer)  almost  always  attacks 
the  face.  "  Patients  usually  describe  it  as  attracting  their  atten- 
tion by  some  trifling  change  in  a  small  spot  of  skin  which 
previously  had  not  been  quite  natural.  Some  mole,  or  wart,  or 
minute  thickening  of  the  skin,  which  they  had  always  known  to 
exist,  or  some  pimple  which  had  grovA-n  up  unnoticed,  began  to 
itch  or  to  be  tender  when  touched ;  and  a  slight  scab,  which  showed 
already  a  breach  of  the  surface,  was  found  to  have  formed  upon  the 
spot"  (C.  H.  Moore).  It  gives  rise  to  a  raised,  red  tubercle,  which 
breaks  and  leaves  a  foul  and  offensive  ulcer,  "  It  spreads  abroad 
in  all  directions  with  a  slow  but  unswerving  advance.  It  grows 
and  ulcerates.  It  ulcerates,  but  never  heals.  The  skin  suffers 
most  widely  from  its  ravages,  but  no  structure  arrests  its  pro- 
gress. It  removes  whole  organs,  but  restores  nothing.  In  its 
front  aU  is  healthy;  behind  it  is  vacancy  and  frightful  disfigure- 
ment. Whilst  eroding  integument,  cartilage,  or  bone,  the  disease 
is  not,  or  is  little  painful;  but  when  eyelids  disappear,  when  the  eye 
or  the  inner  ear  is  invaded,  when  branches  of  the  fifth  nerve  are 


224 


DISEASES  OF  TISSUES  AND   OEGANS. 


exposed,  or  are  ulcerating,  pain,   and  sometimes  severe  pain,  is 
added  to  the  deformity"  (C.  H.  Moore). 

Rodent    cancer  is  a  disease  of   advanced   Kfe.     It   is   never 

spontaneously      curable. 


Fig.  106. 


Eodent  cancer,  from  0.  H.  Moore, 


but    always    tends    to- 
v^rards  a  fatal  issue. 

Treatment.  —  The 
disease  should .  be  cut 
out,  and  the  wound 
treated  with  chloride  of 
zinc  paste,  or  some 
other  suitable  caustic. 
If  the  knife  cannot  be 
used,  the  caustic  should 
be  applied  directly  to  the 
eroding  surface.  By  the 
administration  of  chloro- 
form, and  the  subsequent 
subcutaneous  injection 
of  morphia,  the  patient 
may  be  kept  tolerably 
free  from  suffering. 


The  Diseases  of  the  Eye  next  claim  attention.  I  shall,  how- 
ever, only  speak  of  the  commoner  and  more  superficial  affections 
of  the  organ,  such  as  are  met  with  in  general  surgical  practice, 
without  alluding  to  those  deeper  diseases  which  are  revealed  by 
the  ophthalmoscope. 

OPHTHAI.3IIIA  TARSI  (TINEA  CIIiIARIS). 

By  this  is  meant  an  inflamed  state  of  the  margins  of 
the  lid.  The  disease  seems  to  begin  in  the  Meibomian 
follicles,  and  to  spread  thence  to  the  adjacent  palpebral  con- 
junctiva, and  to  the  edge  of  the  lid.  There  is  an  unnatural, 
viscid  secretion,  which  causes  the  eyelids  to  stick  together  during 
sleep,  and  forms  a  hard,  dry  crust  around  the  roots  of  the 
lashes. 

The  eyelashes  become  stunted  and  irregular,  giving  rise  to 
trichiasis,  and  the  edges  of  the  lids  thickened  and  excoriated. 

There  is  heat  and  irritation,  with  intolerance  of  light. 
The  disease  is  generally  accompanied  by  derangement  of  the 
digestive  organs.  Very  often  it  co-exists  with  a  scrofulous 
habit. 

The  term  lippitudo  is  applied  to  the  chronic  stage  of  the 
disease,  when  the  lasbes  have  disappeared,  and  the  margins  of 


ENCYSTED  TUMOUES  OF  THE  EYELIDS.    225 

the  lids  are  red,  swollen,  and  everted,  from  thickening  of  the 
palpebral  conjunctiva. 

Treatment. — If  the  inflammation  is  acute,  the  eye  should  be 
assiduously  fomented  v?ith  water,  or  with  a  decoction  of  poppy- 
heads  (F.  2),  and  the  patient  should  take  some  mild  aperient  or 
alterative. 

Subsequently,  astringent  or  stimulating  applications  may  be 
used  with  advantage — e.g.,  lotions  of  alum,  or  of  the  sulphate  of 
copper  or  of  zinc  (gr.  j — ij  ad  3J). 

The  edges  of  the  lids  should  be  lightly  touched  at  night  with 
the  zinc  ointment,  or  with  dilute  citrine  ointment  (Ung.  Hydrarg. 
Nitrat.  gr.  x  ad  ^'  adipis).  But  before  this  is  done,  any  crusts 
that  may  have  formed  should  be  softened  with  warm  water,  and 
removed;  otherwise  the'ointment  does  no  good.  It  is  an  excel- 
lent plan  to  touch  the  sore  or  thickened  parts  about  the  roots 
of  the  lashes  with  a  camel's-hair  brush,  which  has  been  moistened 
and  passed  over  a  stick  of  lunar  caustic.  The  lids  should  be  well 
cleaned  before  the  application  is  made,  and  carefully  wiped  with  a 
soft  sponge  immediately  afterwards.  This  may  be  repeated  once 
a  week. 

HORBEOXiXTM, 
or  sfye,  is  an  inflammation  of  one  of  the  ciliary  follicles.  A 
painful  swelling  forms  on  the  margin  of  the  lid.  It  may  either 
suppurate,  or  remain  for  some  time  in  an  indurated  condition,  and 
then  gradually  subside.  It  indicates  a  disordered  or  enfeebled 
state  of  the  health. 

Treatment. — Fomentations  or  poultices  should  first  be  applied. 
When  suppuration  has  taken  place,  it  may  be  relieved  by  a 
puncture,  and  afterwards  treated  with  a  little  stimulating  oint- 
ment. The  patient  should  take  a  purge,  and  then  alteratives 
and  tonics.  His  diet  should  be  regulated,  and  if  he  can  have  a 
change  of  air,  it  will  be  of  advantage  to  him. 

In  the  indurated  condition,  the  cold  water  douche,  combined 
w4th  the  dilute  citrine  ointment,  or  the  nitrate  of  silver  applied 
with  a  camers-hair  pencil,  will  be  found  very  useful. 

EXrCTSTBD  TUMOURS  OF  TH£  E'^EXiIDS 

(TjA.RSil.Ii    CVSTS). 

Encysted  tumours  are  often  met  with  in  the  eyelids, 
especially  in  the  upper.  They  appear  to  be  produced  in 
a  Meibomian  gland,  which  becomes  dilated  and  filled  with 
sebaceous  matter.  They  make  their  way,  either  outwards 
beneath  the  skin,  or  inwards,  so  as  to  present  on  the  conjunctival 
surface.  They  may  remain  of  small  size  for  a  length  of  time, 
and  then  slowly  disappear.     But,  more  frequently,  they  become 


226 


DISEASES   OF    TISSUES  AND   ORGANS. 


inflamed,  and  increase  rapidly,  on  some  slight  cause  of  irritation, 
such  as  dust,  wind,  cold,  &c.     Fig.  107  represents  a  tarsal  cyst 

of  the  lower  lid,  in  a  situation 


Fig.  107. 


where  these  little  tumours  are 
not  very  often  seen. 

Treatment. — The  cyst  should 
be  slit  up  from  the  conjunctival 
aspect,  and  its  contents  squeezed 
out,  or  turned  out  with  a  scoop 
made  for  the  purpose.  The 
point  of  a  probe  should  be  intro- 
duced from  time  to  time  to 
prevent  the  opening  from 
healing  too  quickly.  No  at- 
tempt should  be  made  to  dissect 
the  cyst  out  by  an  incision 
through  the  skin.  Sometimes 
the  dilute  citrine  ointment,  externally  applied,  seems  to  disperse 
these  little  tumours.  • 


Tarsal  cyst  of  the  lower  lid. 


MOIiXiVSCUni  COn-TAGZOSUIVI  (GIiAITDIFOIIAI 
TUIVXOUR). 

These  tumours  are  found  in  the  skin  of  the  cheeks  and 
nose,  but  more  especially  in  that  of  the  eyelids.  They 
are  very  common  among  children.  They  are  hard,  painless, 
and  white,  varying  in  size  from  that  of  a  pin's  head  to  that 
of  a  horse-bean.  They  are  composed  of  granular-looking  matter, 
probably  hypertrophied  sebaceous  gland-structure.  They  are 
seldom  met  with  singly.  They  usually  present  a  small  orifice, 
through  which  a  white  fluid  exudes.  The  disease  is  undoubtedly 
contagious,  but  upon  what  this  depends  is  a  moot  point.  It  is 
tolerably  certain  that  it  is  not  upon  a  parasite.  Perhaps  (as 
Virchow  suggests)  the  sebum  from  one  patient  finds  its  way  into 
the  follicles  of  another,  and  there  produces  a  similar  irritation 
and  overgrowth. 

The  readiest  treatment  is  to  divide  the  tumour  across,  and  press 
out  the  contents  between  the  thumb  nails.  This  proceeding 
seems  rude,  but  it  is  effectual,  and  gives  very  little  pain. 

TRICHIASIS 

is  a  perverted  condition  of  the  cilia,  in  which  they  have  a  ten- 
dency to  grow  inwards.  It  is  a  frequent  result  of  ophthalmia 
tarti.  The  whole  line  of  lashes  may  be  affected,  or  only  a  part 
of  it.  Tlie  eye  becomes  irritated,  and  its  surface  is  kept  in  a 
chronic  state  of  inflammation. 


ECTROPION.  227 

Treatment. — The  disease  may  be  palliated  by  pulling  out  the 
offending  hairs  from  time  to  time  by  means  of  a  suitable  pair  of 
forceps.  If  this  fails,  the  portion  of  skin  containing  the  follicles 
of  the  faulty  lashes  may  be  dissected  out.  Sometimes  the  whole 
of  both  rows  requires  to  be  removed  in  this  way. 

EN-TROPZOM- 

signifies  an  inversion  of  the  lid.  It  is  necessarily  attended  by 
trichiasis,  and  gives  rise  to  great  irritation.  It  may  be  the 
result  of  a  cicatrix  in  the  conjunctiva,  or  of  a  neglected  attack 
of  strumous,  or  purulent,  ophthalmia.  Or  it  may  arise  from 
other  causes,  such  as  relaxation  of  the  skin  of  the  lid,  more 
especially  of  the  lower.  It  not  unfrequently  follows  operations 
upon  the  eye  in  elderly  people.  Cicatrices  in  the  conjunctiva  are 
very  apt  to  result  from  the  use  of  too  powerful  applications. 

Treatment. — When  the  entropion  is  slight,  it  may  be  treated  by 
contractile  substances  applied  to  the  outside  of  the  lid — collodion, 
for  example.  If  this  is  not  sufficient  to  meet  the  case,  some  one 
of  the  many  operations  that  have  been  proposed  for  the  cure  of 
the  deformity  will  have  to  be  undertaken.  These  operations 
consist,  either  in  removing  a  narrow  strip  of  skin  and  muscle 
parallel  to  the  ciliary  margin,  so  as  to  produce  eversion  by  con- 
traction of  the  cicatrix,  or  else  in  taking  away  the  entire  row  of 
eyelashes.  Burow  has  lately  introduced  a  different  method  of 
dealing  with  these  cases.  He  makes  an  incision  along  the  margin 
of  the  lid  between  the  row  of  lashes  and  the  conjunctival  surface, 
so  as  to  separate  the  skin  (with  the  row  of  lashes)  from  the 
cartilage,  for  such  a  depth  as  may  seem  necessary  and  along  the 
whole  of  the  inverted  portion.  Then,  if  it  is  needful,  he  removes 
a  strip  of  skin  and  muscle  from  the  further  part  of  the  lid,  as  in 
the  old  operation. 

ECTROPIOM- 

means  the  eversion  of  the  lid — the  opposite  condition  to  the 
foregoing.  The  palpebral  conjunctiva  becomes  visible,  red  and 
thickened,  and  the  eyeball  is  exposed.  It  may  be  caused  by  abscess 
at  the  margin  of  the  orbit,  or  by  the  contraction  of  a  cicatrix 
on  the  face,  or  by  inflammation  and  thickening  of  the  conjunctiva, 
or  by  the  dropping  of  the  lower  lid  as  a  consequence  of  paralysis. 
Treatment. — Little  or  nothing  can  be  done  short  of  an  opera- 
tion, and  the  precise  nature  of  such  an  operation  will  depend 
upon  the  peculiar  features  of  the  case.  Sometimes  the  redundant 
and  thickened  conjunctiva  may  be  removed  with  scissors;  some- 
times a  V-shaped  portion  of  the  lid  may  be  excised  ;  sometimes  a 
flap  of  skin  may  have  to  be  transposed,  and  a  plastic  operation 
performed. 

Q2 


228  DISEASES  OF  TISSUES  AND  ORGANS. 


PTOSIS 

denotes  a  drooping  of  the  upper  lid,  which  produces  hoth  de- 
formity and  inconvenience.  It  depends  upon  paralysis  of  some 
portion  of  the  third  nerve.  Such  paralysis  may  be  congenital,  or 
it  may  he  brought  about  by  mere  debility,  or  it  may  be  caused 
by  disease  of  the  brain,  either  functional  or  organic.  It  is,  there- 
fore, not  so  much  a  disease  in  itself  as  an  indication  of  disease 
elsewhere.  Sometimes  it  arises  without  any  assignable  cause, 
and  persists  in  defiance  of  every  remedy.  In  such  cases  the 
patient  generally  acquires  a  certain  degree  of  power  over  the  lid 
by  the  action  of  the  orbicularis  palpebrarum  muscle.  It  some- 
times follows  exposure  to  cold  winds,  especially  in  rheumatic 
subjects. 

Treatment. — If  the  ptosis  depends  upon  debility,  we  must  en- 
deavour to  give  tone  and  vigour  to  the  system  by  a  course  of 
strengthening  medicines,  and  by  a  regulated  manner  of  Hfe.  If 
no  cause  can  be  assigned,  and  the  disease  does  not  yield  to  milder 
treatment,  a  strip  of  the  skin  at  the  upper  margin  of  the  orbit 
may  be  removed,  so  as  to  raise  the  lid  by  the  contraction  of  the 
cicatrix.  If  the  ptosis  depends  upon  disease  of  the  brain,  it  will 
often  be  found  to  be  of  syphilitic  origin.  If  it  follows  exposure, 
the  alkalies  and  colchicum  (F.  56,61)  may  be  given  with  advantage. 
Galvanism  is  sometimes  beneficial  for  these  cases,  but  must  be 
used  with  caution. 

EPIPHORA — STIIiXiICIBIUM    IiACHRYMARUM. 

Epiphora  signifies  an  overflow  of  tears,  the  result  of  hyper- 
secretion. When  the  overflow  arises  from  obstruction  to  the 
onward  passage  of  the  tears,  it  is  called  stillicidium  laohrymarum. 
The  term  epiphora  is  sometimes  applied  indifierently  to  both  of 
these  conditions. 

Epiphora  may  depend  upon  an  irritable  state  of  the  lachrymal 
gland,  or  of  the  entire  surface  of  the  eye.  It  is  a  frequent  accom- 
paniment of  the  scrofulous  diseases  of  that  organ. 

Treatment. — The  eye  should  be  treated  with  sedative  or 
astringent  coUyria  (F.  16,  25).  At  the  same  time,  the  general 
health  should  be  amended  by  alteratives  and  tonics,  and  by  a 
regulated  diet.  In  all  cases  the  eye  should  be  carefully  examined, 
to  see  if  any  particle  of  sand,  eyelash,  or  other  foreign  body  is 
present.  Sometimes  a  loose  lash  becomes  lodged  in  the  punctum, 
where  it  may  easily  escape  notice. 

Stillicidium  lachrymarum  may  arise  from  a  variety  of  causes- 
closure    or    disi)lacement    of    the    puncta,    contraction    of   the 


FISTULA  LACHEYMALIS.  229 

canalicnli,  inflammation  of  tbe  sac,  or  thickening  of  the 
duct. 

The  treatment  consists  in  allaying  the  acute  inflammation,  if 
that  is  the  cause  of  the  impediment,  and  making  a  free  passage 
for  the  tears.  If  the  disease  depends  upon  some  other  cause,  the 
canaliculi  should  be  slit  up  to  the  inner  canthus  on  a  grooved 
director,  introduced  at  the  puuctum,  in  the  way  recommended  by 
Mr.  Bowman.  If  the  duct  is  obstructed,  a  nasal  probe  should 
be  passed  into  the  nose  from  time  to  time. 

OBSTRITCTION*  OF  TBE  ITASiLIi  DXTCT 

seems  to  arise  from  inflammatory  thickening  of  the  mucous  mem- 
brane hning  it.  It  is  often  associated  with  the  scrofulous  habit. 
The  only  treatment  is-  to  lay  open  the  canalculi,  as  explained 
above,  and  then  to  pass  suitable  probes  along  the  duct  until  the 
natural  passage  is  restored. 

lUFiiAniniATzosr  of  the  IiAchrtmak  sac 

may  be  either  acute  or  chronic.  The  chronic  variety  (mucocele) 
is  often  an  extension  of  the  disease  from  the  nasal  duct.  It  is 
marked  by  tenderness  and  swelling.  A  muco-purulent  secretion 
can  be  squeezed  upwards  through  the  puncta.  When  the  inflam- 
mation is  acute,  there  is  pain,  redness,  and  rapid  distension,  so  that 
the  sac  threatens  to  burst. 

Treatment. — The  chronic  inflammation  should  be  treated  by 
slitting  up  the  canaliculi,  and  passing  a  probe  into  the  nose,  to  as- 
certain that  the  passage  is  clear.  The  patient  should  frequently 
empty  the  sac  by  squeezing  the  contents  downwards  into  the 
nose.  At  the  same  time,  the  general  health  should  be  carefully 
regulated. 

The  acute  inflammation  requires  active  antiphlogistic  mea- 
sures— pui'gatives,  leeches,  fomentations,  &c.  When  suppuration 
has  taken  place,  the  sac  should  be  opened  freely  by  an  incision 
through  the  skin  at  the  most  prominent  part,  downwards  and 
outwards,  and  poultices  applied. 

FISTVIiA  XiACBRTMAXiIS. 

When  the  sac  suppurates  and  bursts,  or  when  it  is  punctured 
through  the  skin,  one  of  two  things  will  happen — either  the 
inflammation  may  subside,  the  tears  may  take  their  natural  course, 
and  the  external  opening  may  heal,  or  the  duct  may  be  left 
permanently  obstructed,  and  the  tears  may  make  their  way 
through  the  external  opening,  and  flow  over  the  cheek.  The 
latter  condition  is  called ^s-^wZa  lachrymalis. 

Treatment. — Our  aim  is  to  open  up  a  free  passage  for  the  tears 


230  DISEASES  OF  TISSUES  AND  OEGANS. 

through  the  lachrymal  sac  and  nasal  duct;  and  then  the  wound 
in  the  skin  will  close  of  itself.  With  this  view,  the  lower  punc- 
turn  and  canaliculus  may  be  slit  up,  and  probes  passed  from  day 
to  day  until  the  passage  is  re-established. 

SIAIPI.E  con-juircTiviTzs 

may  be  either  acute  or  chronic. 

In  the  acute  form  there  is  heat,  pain,  irritation,  intolerance  of 
light,  with  a  sensation  as  if  there  were  sand  under  the  lids.  On 
opening  the  eye,  the  conjunctiva  is  seen  to  be  of  a  bright  scarlet 
hue.  The  vessels  are  tortuous  and  injected,  making  their  way 
from  the  margins  of  the  globe  towards  the  cornea.  That  they 
are  no  deeper  than  the  conjunctiva  is  evident,  for  they  shift  their 
position  as  the  membrane  is  moved.  The  secretion  of  tears  is 
excessive,  especially  on  opening  the  eyes.  The  digestive  organs 
are  generally  disordered,  and  there  is  headache  and  feverishness. 

The  disease  may  be  caused  by  the  irritation  of  a  foreign  body, 
by  over-use,  by  exposure  to  the  glare  of  the  sun,  &c.  Most 
frequently,  however,  it  arises  from  cold  and  wet-ir-the  patient 
"  catches  a  cold  in  his  eye." 

Treatment. — The  cause  should,  if  possible,  be  removed.  The 
patient  should  be  purged,  should  wear  a  shade  over  both  eyes, 
and  should  stay  indoors  for  a  few  days.  The  eye  should  be  well 
fomented  with  plain  water,  or  with  a  decoction  of  poppyheads 
(F.  2),  and  the  edges  of  the  lids  should  be  smeared  with  fresh 
unsalted  lard.  Vaseline,  prepared  from  petroleum,  is  excellent 
for  this  purpose,  as  well  as  for  most  purposes  for  which  lard  or 
simple  ointment  is  used.  If  there  is  much  pain,  and  particularly 
if  the  patient  is  plethoric,  leeches  should  be  applied  to  the 
temples. 

When  the  acute  symptoms  are  beginning  to  subside,  the  eye 
should  be  frequently  bathed  with  cold  water,  or  with  astringent 
lotions  (F.  15,  16).  At  the  same  time  a  solution  of  nitrate  of 
silver,  or  of  sulphate  of  zinc  (gr.  j — ij  ad  ^j),  should  be  dropped 
into  the  eye  twice  a  day.  After  the  bowels  have  been  freely 
opened,  the  patient  should  have  a  light  but  nutritious  diet. 

The  chronic  form  may  arise  from  a  continued  irritation,  as  of 
inverted  lashes ;  or  it  may  be  a  sequel  to  the  acute  disease.  In 
the  latter  case  it  is  generally  associated  with  disordered  and  en- 
feebled health. 

Treatment. — If  the  inflammation  is  the  result  of  a  previous 
acute  attack,  it  will  require  to  be  treated  by  stimulant,  astringent, 
or  sedative  collyria,  as  a  solution  of  nitrate  of  silver,  or  the  vinum 
opii.  Occasionally  a  leech  or  a  blister  may  be  applied  to  the 
temple.     But  the  most  important  point  is  to  improve  the  general 


PUEULEXT  CONJUNCTIVITIS.  231 

health  by  alteratives,  tonics,  exercise  in  the  open  air,  and  a 
regulated  diet. 

CATARRHAIi   OPHTHAIiMIA 

is  a  variety  of  the  simple  inflammation,  characterised  by  more  or 
less  swelling  of  the  conjunctiva  {chemosis),  and  by  small  extrava- 
sations of  blood  scattered  over  the  surface.  There  is  much 
lachrymation,  and  a  thin  muco-purulent  discharge,  which  often 
becomes  thick  and  creamy,  and  is  no  doubt  contagious. 

The  treatment  must  depend  in  a  great  measure  upon  the  indi- 
vidual case.  Sometimes  warmth  and  poppy  fomentations  give 
most  relief.  In  other  cases,  cold  water,  or  astringent  applications, 
as  the  nitrate  of  silver  (gr.  j — ij  ad  5J),  or  alum  (gr.  ij — vj  ad 
5J),  dropped  into  the  eye,  are  found  most  beneficial. 

The  bowels  should  be  kept  open,  but  the  patient  must  not  be 
lowered.  The  usual  diet  should  be  given,  and  in  some  cases  wine 
and  bark  may  be  added  with  advantage.  The  eye  should  be  kept 
very  clean.  The  discharge  and  incrustation  should  be  removed 
with  tepid  water,  and  a  little  simple  ointment  or  cold  cieam 
applied  to  the  edges  of  the  lids. 

PURUI.SITT   COXJTTTN'CTIVITIS 

is  an  aggravated  form  of  the  preceding.  The  principal  diffe- 
rence is  in  the  severity  of  the  symptoms  and  in  the  character  of 
the  discharge. 

Symptoms. — There  is  great  irritation,  and  pain  shooting 
through  the  head,  the  eyelids  are  swollen  and  oedematous,  so  that 
the  eye  is  closed,  the  conjunctiva  is  tumid  from  infiltration  of 
serum  and  lymph,  the  vessels  are  gorged  with  blood,  giving  the 
membrane  a  bright  red  tint,  and  a  rough  irregular  surface.  This 
roughness  is  most  marked  on  the  palpebral  portion.  When  it 
persists,  it  constitutes  the  condition  known  as  granular  con- 
junctiva. The  cornea  is  more  apt  to  be  affected  in  this  variety 
than  in  the  simple  catarrhal  inflammation.  There  is  profuse 
secretion  of  purulent  matter.  The  constitutional  symptoms  are 
severe  in  proportion. 

The  disease  maybe  caused  by  injury,  over-crowding,  deficient 
ventilation,  want  of  cleanliness,  exposure  to  intense  glare,  or  to  cold 
and  wet.  It  is  highly  contagious.  In  Egypt  it  occurs  as  an 
epidemic,  from  the  combined  effects  of  sun,  wind,  and  sand.  It 
is  said  to  be  propagated  there  by  the  flies. 

It  may  lead  to  sloughing  of  the  cornea,  disorganization  of  the 
eyeball,  or  granular  conjunctiva. 

Treatment. — A  brisk  purgative  should  be  given,  and  a  few 
leeches  applied,  if  there  is  much  heat  and   pain.     As  there  is 


232  DISEASES  OF  TISSUES  AND   ORGANS. 

generally  considerable  depression,  a  good  diet,  with  wine^ 
ammonia,  and  bark,  maybe  required  from  the  first  (F.  34,  35). 
But  for  this  no  precise  rule  can  be  laid  down.  The  surgeon  must 
be  guided  by  the  symptoms  in  each  particular  case.  The  patient 
should  be  confined  to  the  house  for  a  time,  and  have  his  room 
darkened,  but  well  supplied  with  fresh  air.  The  eyes  should  be 
constantly  fomented,  and  every  hour  or  half-hour  they  should  be 
syringed  out — first  with  warm  water,  so  as  to  get  rid  of  the 
secretion,  and  then  with  an  astringent  lotion,  which  may  be  com- 
posed of  alum,  sulphate  of  zinc,  tannin,  or  nitrate  of  silver. 
This  application  may  be  combined  with  sedatives,  or  opium  may 
be  given  by  the  mouth.  It  is  a  good  plan  for  the  surgeon  him- 
self to  inject  a  solution  of  nitrate  of  silver  (gr.  ij — iv  ad  ^j)  once 
every  day,  for  it  frequently  happens  that  through  timidity,  or 
unskilfulness,  the  syringing  is  not  so  efifectually  done  as  to  wash 
every  part  of  the  conjunctiva.  At  night  the  edges  of  the  lids 
should  be  touched  with  simple  ointment  or  cold  cream. 

The  greatest  care  should  be  exercised  to  keep  separate  all 
sponges,  towels,  handkerchiefs,  &c.,  used  by  the  patient,  so  as  to 
prevent  contagion. 

When  the  acute  symptoms  have  subsided,  a  solution  of  nitrate 
of  silver  (gr.  j — ij  ad  ^j)  may  be  dropped  into  the  eye  twice  a  day, 
and  a  blister  occasionally  applied  to  the  temple.  Strengthen- 
ing medicines  should  be  continued  for  some  time  after  the  disease 
has  been  arrested. 

OPHTHAIimiA   XJEO^ATORTTIVC 

is  the  name  given  to  purulent  conjunctivitis,  when  it  occurs  in 
children  a  few  days  after  birth.  In  such  cases  it  most  probably 
arises  from  the  infection  of  a  vaginal  discharge  in  the  mother. 
It  may,  however,  result  from  a  want  of  proper  cleanliness,  from 
excessive  exposure  to  light,  or  other  causes. 

The  symptoms  are  those  of  acute  purulent  conjunctivitis. 

The  special  treatment  consists  in  syringing  the  eye,  every  hour 
or  half-hour,  with  an  alum  lotion  (gr.  v  ad  ^j),  so  as  to  wash 
away  the  secretion  as  fast  as  it  forms.  Simple  ointment  or  vase- 
line should  be  smeared  along  the  lids.  The  constitutional  treat- 
ment should  on  no  account  be  neglected.  Two  or  three  drops 
of  liq.  cinchonse  and  sal  volatile  in  ^j  of  water  may  be  given  with 
benefit  every  three  hours. 

If  taken  in  time,  and  perseveringly  treated,  the  inflammation 
generally  subsides,  without  leaving  any  ill  effects  behind  it. 

As  any  one  lotion  seems  after  a  time  to  lose  its  effect,  it  is 
well  to  vary  the  applications  occasionally,  or  to  combine  them 
(F.  26).     In  these  cases,  too,  the  surgeon  may  now  and  then 


STRUMOUS  OPHTHALMIA.  233 

apply  the  stronger  solution  of  nitrate  of  silver  with  advan- 
tage (Gr.  ij— iv.  ad.  3J). 

The  extreme  ectropion,  which  sometimes  occurs  in  cases  of  this 
kind,  generally  disappears  as  the  eye  becomes  stronger.  It  may, 
however,  be  alleviated  by  an  elastic  band  placed  round  the  head, 
and  passing  over  small  soft  pads  fitted  upon  the  lids. 

GOirORRHCEAIi  OPIITHAI1MZ.A. 

is  the  most  aggravated  form  of  purulent  conjunctivitis.  It  is 
excited  by  the  application  of  gonorrhceal  matter  to  the  eye. 

The  symptoms  are  essentially  the  same  as  those  of  the  acute 
purulent  conjunctivitis.  They  are,  however,  very  intense,  and 
run  a  rapid  course.  Unless  the  disease  is  arrested,  it  leads  in  a 
very  short  time  to  sloughing  of  the  cornea,  and  protrusion  of  the 
contents  of  the  eyeball. 

The  treatment  should  be  prompt  and  active.  It  must  be  con- 
ducted on  the  principles  already  laid  down  in  speaking  of  acute 
purulent  conjunctivitis.  Especial  care  should  be  taken  lest  the 
discharge  from  the  affected  eye  be  conveyed  to  the  other.  The 
sound  eye  should  therefore  be  kept  closed  by  a  clean  pad  of 
cotton-wool.  Of  course  equal  precautions  must  be  taken  that  no 
one  else  becomes  inoculated  with  the  purulent  matter.  The  eye 
should  be  bathed  and  wiped  with  clean  pieces  of  linen  rag,  each 
piece  being  burnt  immediately  after  use. 

However  successful  the  treatment  may  be,  it  is  almost  sure  to 
be  followed  by  more  or  less  granulation  of  the  conjunctiva.  This 
should  be  promptly  attended  to,  lest  it  should  become  chronic, 
when  it  would  be  much  more  difficult  to  cure.  Bluestone  may 
be  applied  in  the  solid  form  ;  or  finely-powdered  acetate  of  lead 
may  be  spread  upon  the  everted  lid,  and  rubbed  into  the  folds  and 
crevices  of  the  conjunctiva,  care  being  taken  to  wash  away  the 
superfluous  substance,  by  means  of  a  stream  of  tepid  water  from 
an  elastic  bottle,  before  the  lid  is  returned  to  its  proper  position. 
The  application  may  be  repeated  once  a  week.  In  the  intervals, 
a  solution  of  sulphate  of  copper  or  zinc,  or  of  nitrate  of  silver 
(gr.  ij  ad  ^'),  may  be  dropped  into  the  eye  with  a  quill,  or  camel's- 
hair  brush,  two  or  three  times  a  day. 

As  the  nervous  irritability  and  the  mental  depression  are 
usually  very  great,  stimulants — e.g.,  ammonia,  brandy,  cham- 
pagne— and  a  liberal  diet  should  always  be  ordered. 

STRXnVIOUS   OPHTHAIiMIA 

is  a  disease  which  is  very  common  among  scrofulous  children. 

Symptoms. — The  conjunctiva  is  slightly  and  irregularly  vascular, 
and  in  the  centre  of  each  patch  of  enlarged  vessels  is  a  small 


234  DISEASES  OF  TISSUES  AND   ORGANS. 

pimple  or  pustule  {pJilyctenula).  This  is  generally  seated  on,  or 
near,  the  margin  of  the  cornea.  There  is  usually  great  intolerance 
of  light.  The  child  buries  its  head  to  avoid  exposure.  The  eye- 
lids are  forcibly  contracted,  and  the  lashes  inverted.  In  other 
cases,  however,  there  is  little  or  no  photophobia,  and  but  slight 
pain.  Tears  are  constantly  trickling  over  the  cheeks.  With 
this  there  are  the  general  marks  of  scrofula. 

Treatment. — The  local  irritation  may  be  allayed  by  fomenta- 
tions, by  anodyne  drops,  especially  of  the  sulphate  of  atropine 
(gr.  j  ad  ^j),  or  by  rubbing  belladonna  ointment  round  the  eye, 
while  conium,  henbane,  or  opium  is  given  internally.  If  the 
disease  is  of  long-standing,  counter-irritation  to  the  temples,  by 
iodine  tincture,  or  blisters,  or  a  seton,  may  be  very  useful.  In 
the  chronic  stage  a  solution  of  nitrate  of  silver  (gr.  j — ij  ad  gj) 
should  be  dropped  into  the  eyes  at  night. 

Care  should  be  taken  to  smear  the  lids  with  simple  ointment, 
so  as  to  prevent  them  from  sticking  together  during  sleep. 
When  there  is  no  photophobia,  calomel,  dusted  into  the  eye  with 
a  brush,  often  does  good.  If  the  first  application  causes  much 
pain  and  irritation,  it  must  not  be  continued  ;  otherwise  it  may 
be  repeated  daily,  and  even  for  a  few  days  after  the  phlyctenula 
has  disappeared.  The  same  treatment  is  useful  for  the  ulcers 
which  are  sometimes  left  when  the  pustule  has  been  situated  on 
the  cornea.  But  the  most  important  part  of  the  treatment  is 
the  constitutional.  Fresh  air,  and,  if  possible,  a  residence  at  the 
sea-side,  moderate  exercise,  a  regulated  diet,  alteratives,  cod-liver 
oil,  the  preparations  of  quinine  and  iron — especially  the  syrup  of 
the  iodide  and  phosphate  (F.  45,  48,  65,  66) — these  are  the 
remedies  which  are  most  likely  to  do  good. 

GRiLUJUZiAR    COirJUN-CTZV.A. 

has  been  already  alluded  to  as  a  condition  which  is  apt  to  remain 
after  an  attack  of  purulent  ophthalmia.  It  depends  upon  a 
thickened  and  hypertrophied  state  of  the  mucous  membrane  of 
the  palpebral  conjunctiva.  The  papillse  become  prominent  and 
irregular,  so  as  to  give  the  appearance  of  a  granulating  surface. 

It  is  easy  to  understand  that  this  rough  surface  rubbing  up 
and  down  aggravates  any  inflammation  that  may  exist,  and 
keeps  up  a  chronic  state  of  irritation,  so  that  in  course  of  time 
it  renders  the  cornea  opaque,  like  ground  glass. 

Treatment. — Our  aim  is  to  destroy  the  granulations.  With 
this  view  they  may  be  touched  with  nitrate  of  silver  or  sulphate 
of  copper,  in  the  solid  form  or  in  solution.  Some  recommend 
the  liquor  potassae ;  others  the  acetate  of  lead  ;  others,  again, 
prefer  counter-irritation  on  the  outside  of  the  lids.     In  any  case 


INFLAMMATION  OF   THE  CORNEA. 


235 


the  state  of   the  general  health  ought  on    no  account   to   be 
neglected. 

When  the  whole  cornea  has  become  hazy,  and  has  large  vessels 
ramifying  throughout  it,  it  is  the  modern  practice  to  inoculate 
the  eye  with  purulent  matter,  so  as  to  set  up  an  acute  inflam- 
mation. This  leads  to  the  destruction  of  the  granulations,  as 
well  as  to  the  absorption  of  tlje  effused  lymph,  upon  which  the 
"  ground  glass"  appearance  of  the  cornea  depends.  By  this 
means  a  valuable  degree  of  sight  is  often  restored  to  the  patient. 
But  inoculation  must  never  be  employed,  unless  the  cornea  h 
vascular  and  hazy  in  every  part. 

PTERYGIUM 

is  the  name  given  to  a  thickening  or  fleshy  growth  of  the  ocular 
conjunctiva.     It  generally  takes  something  of  a  triangular  shape 
with     its    apex    towards    the 
cornea.      Of    its     causes    and  ^^' 

pathology  nothing  is  known. 
A  large  proportion  of  those 
who  are  affected  by  it  have 
lived  for  a  longer  or  shorter 
time  in  the  tropics.  At  first, 
it  is  only  unsightly,  but  by 
degrees,  as  it  encroaches  on 
the  cornea,  it  interferes  with 
vision.  Fig,  108  was  drawn 
from  a  sailor  who  had  served 
on  the  West  Indian  station. 
Both  his  eyes  were  symmetri- 
cally affected. 

The  most  effective  treatment 
is  transplantation.  The  growth 
is  dissected  off  as  far  as  the 
base,  then  turned  back,  and 
received  into  a  slit  in  the 
conjunctiva,  where  it  is  kept  in  place  by  two  or  three  stitches. 
In  this  position  it  gradually  wastes,  and  disappears;  but  when 
entirely  excised  it  has  a  great  tendency  to  return. 

UarFIiAMXtZATZOIl'  OF  THE  CORirEii.  (KERATITIS, 
CORIUEITIS). 

The  inflammation  may  begin  either  in  the  cornea  itself,  or  it 
may  spread  to  it  from  an  adjacent  tissue. 

It  may  be  caused  by  an  injury,  or  by  debility,  or  by  a  specific 
poison  in   the  blood.     It  is  very  common  in  scrofulous  children, 


Pterygium. 


236  DISEASES  OF  TISSUES  AND  ORGANS. 

and  in  the  subjects  of  hereditary  syphilis.  It  may  be  either 
superficial  or  deep-seated ;  and  it  may  lead  to  the  effusion  of 
lymph,  or  to  suppuration,  or  to  ulceration,  or  to  sloughing. 

Symptoms. — There  is  pain  in  the  eye  and  head,  a  constant 
flow  of  tears,  intolerance  of  light,  haziness  and  vascularity  of 
the  cornea,  with  a  dilated  state  of  the  vessels  of  the  sclerotic, 
which  form  a  fringe  around  the  margins  of  the  cornea.  When 
the  disease  has  advanced  further,  there  may  be  ulceration,  or 
suppuration,  or  pus  in  the  anterior  chamber. 

Treatment. — A  calomel  purge,  fomentations,  anodyne  lotions, 
sometimes  a  few  leeches,  counter-irritation  by  blisters,  or  iodine 
paint  applied  to  the  temples — these  are  the  best  remedies. 
Stimulating  applications  should  be  avoided.  The  patient  should 
wear  a  projecting  shade  over  both  eyes,  have  good  food,  and 
plenty  of  fresh  air.  He  should  also  take  a  course  of  strengthening 
medicine,  with  alteratives.  If  there  is  evidence  of  scrofula,  cod- 
liver  oil  and  steel  should  be  given.  If  there  is  a  syphilitic  taint, 
mercurials  or  the  iodide  of  potassium  will  be  necessary  (F.  49,  50). 

ABSCESS  OF  THE  CORXTEA 

is  one  of  the  results  of  keratitis.  The  matter  forms  between  the 
layers,  either  in  patches,  or  else  it  sinks  down  to  the  bottom,  and 
appears  in  a  crescentic  shape  (onyx). 

Treatment. — Atropine  or  belladonna  lotions  (F.  1)  to  allay 
pain,  fomentations,  counter-irritation  to  the  temples,  good  food, 
tonics,  and  stimulants — these  are  the  means  upon  which  we  rely. 

If  the  pus  is  not  absorbed,  the  abscess  will  either  burst  through 
the  posterior  elastic  lamina  into  the  anterior  chamber,  forming 
hypopyon ;  or  else  it  will  make  its  way  forwards,  and  produce  an 
ulcer  of  the  cornea.  It  is  sometimes  of  advantage  to  puncture 
the  cornea  at  the  seat  of  the  abscess ;  or,  if  there  is  great  pain, 
to  evacuate  the  aqueous  humour  by  a  broad  needle  passed  through 
the  corneal  margin. 

VIiCER  OF  THE  CORITEA 

is  often  the  consequence  of  keratitis ;  but  it  may  arise  from  other 
causes,  as  debility,  injury,  or  a  superficial  pustule. 

Ulcers  of  the  cornea  follow  the  same  general  types  as  ulcers  else- 
where. Sometimes  they  are  acute,  spreading  rapidly,  and  with 
sharply-cut  margins  ;  sometimes  they  are  irritable,  attended  by 
great  pain,  lachrymation,  and  photophobia ;  sometimes  they  are 
healthy  and  healing,  the  edges  rounded  off,  and  the  surface 
covered  with  a  greyish  effusion  of  plastic  lymph. 

Treatment, — In  the  case  of  the  healing  ulcer,  we  have  nothing 
to  do  but  to  "  let  well  alone ;"  to  give  the  eye  perfect  rest,  and 
to  support  the  general  health.     When  the  ulcer  is   irritable. 


STAPHYLOMA.  237 

fomentations  and  atropine  or  belladonna  lotions  should  be  used. 
If  the  rest  is  disturbed,  sedatives  may  be  given  at  night.  Some- 
times a  rapid  improvement  is  effected  by  keeping  the  eye  closed 
with  a  soft  compress  and  bandage.  In  other  cases,  when  there  is 
great  pain,  or  a  threatening  of  perforation,  the  puncture  of  the 
cornea  with  a  broad  needle,  to  allow  the  escape  of  the  aqueous 
humour,  is  of  much  benefit.  If  the  ulcer  is  in  the  acute  stage, 
leeches,  or  counter-irritation,  applied  to  the  temples,  and  ano- 
dyne lotions,  are  the  best  remedies.  Lead  should  never  be 
used,  as  it  is  apt  to  leave  a  permanent  stain  on  the  surface  of 
the  ulcer. 

The  cicatrix  which  is  left  after  an  ulcer  heals  is  always  rather 
opaque ;  except  in  the  case  of  the  most  superficial  ulcers,  which 
may  leave  no  trace  behind  them. 

Atropine  and  belladonna  lotions  are  almost  always  of  value,  not 
only  by  dilating  the  pupil,  and  keeping  the  iris  from  approaching 
the  cornea,  but  also  from  their  soothing  and  anodyne  influence. 

OPACITY  OF  THE  CORirBA. 

The  opacity  which  results  from   the  healing  of  a  cicatrix  is 
called  leucoma.     But  there  is  another  kind  of  opacity,  resulting 
from  the  deposit  of  lymph  between 
the  layers  of  the  cornea,  or  between  Fig.  109. 

it  and  the  conjunctiva.  When  such 
deposit  is  only  slight,  and  has  a 
cloudy,  diffused  chai-acter,  it  is 
termed  a  nebula ;  when  it  is  denser, 
and  presents  a  pearly  appearance,  it 
forms  albugo.  Fig.  109  was  taken  from 
a  remarkable  case  of  congenital 
leucoma,  which  occurred  at  the 
Royal  London  Ophthalmic  Hospital 
at  the  time  I  was  Mr.   Bowman's  Leucoma. 

clinical  assistant. 

Little  or  nothing  can  be  done  to  remove  these  opacities.  In 
children,  they  often  gradually  disappear  in  the  lapse  of  months  or 
years.  After  the  age  of  puberty,  they  rarely  undergo  much 
alteration,  if  they  have  existed  for  any  length  of  time ;  but  in 
the  more  recent  cases,  counter-irritation  by  blisters  or  setons, 
stimulating  lotions,  and  tonic  medicines,  may  be  of  use. 

The  opacity  resulting  from  granular  conjunctiva  has  been 
already  mentioned,  and  its  appropriate  treatment  explained. 

STAPBVI.03MEA  (ATO-TERIOR) 

is  the  term  applied  to  a  protrusion  on  the  anterior  surface  of  the 
eyeball.     It  may  result   from  a  wound,  or  from  the   partial,  or 


238 


DISEASES   OF  TISSUES  AND   ORGANS. 


complete,  destruction  of  a  portion  of  the  cornea  by  ulceration. 
If  there  is  only  a  small  hole  perforated  in  the  cornea,  then  a 
part  of  the  iris  alone  will  protrude  (s.  iridis).  But  if  a  large 
portion  of  the  cornea  has  either  been  destroyed  or  weakened, 
there  will  be  an  extensive  protrusion.  This  becomes  covered 
with  a  fibrinous  deposit,  and  gradually  increases  in  size,  until  it 

may  contain  the  lens  and 
Fig.  110.  a  considerable   portion  of 

the  vitreous  body. 

Treatment, — In  the  for- 
mer case  the  lids  should 
be  kept  closed  with  a 
pad  and  bandage.  The 
protrusion  may  be  punc- 
tured from  time  to  time, 
or  touched  with  lunar 
caustic,  or  even  entirely 
snipped  off.  It  will  then 
shrink,  and  nothing  re- 
main but  a  scar.  In  the 
latter  case,  the  best  thing 
Staphyloma.  that    can  happen    is  that 

the  staphyloma  should 
collapse,  so  as  to  allow  the  patient  to  wear  an  artificial  eye. 
Sometimes  a  free  incision  is  made  across  the  protrusion  with  this 
view.  Sometimes  the  staphyloma  is  sliced  off.  Sometimes  the 
operation  of  ''abscission"  is  performed,  according  to  Mr. 
Critchett's  method.  Lastly,  the  entire  globe  may  be  extirpated. 
Fig.  110  represents  a  staphyloma  which  was  congenital.  The 
mother  accounted  for  it  by  saying  that,  when  she  was  pregnant, 
she  had  had  a  longing  for  grapes. 

CONICAIi  CORZrEA. 

Sometimes  the  cornea,  without  losing  its  transparency, 
gradually  assumes  a  conical  shape.  This  gives  the  surface  a 
peculiarly  bright,  suffused  appearance.  Generally,  both  eyes 
become  affected  in  a  greater  or  less  degree.  As  the  disease 
advances,  it  seriously  impairs  the  sight.  The  apex  of  the  cone 
becomes  thinned  and  nebulous,  and  may  at  length  give  way. 

The  treatment  is  unsatisfactory.  Sometimes  concave  glasses 
are  useful.  Sometimes  the  patient  can  see  tolerably  well  by 
looking  through  a  small  hole,  or  slit,  pierced  in  a  plate  of  black 
wood  or  metal.  Sometimes  both  these  remedies  can  be  combined. 
Iridectomy  seems  to  arrest  the  progress  of  the  disease,  as  well  as 
to  improve  vision,  by  allowing  the  rays  of  light  to  enter  the  eye 


SCLEEOTITIS. 


239 


"^y  - 


through  the  less  conical  portion  of  the  cornea.  The  late  Pro- 
fessor von  Graefe  shaved  off  a  thin  slice  from  the  apex  of  the 
cone,  and,  by  touching  the  point  at  intervals  with  nitrate  of  silver, 
caused  a  cicatrix,  and  thereby  lessened  the  conicity.  Mr.  Bow- 
man removes  with  a  trephine  and  a  sharp  knife  a  small  layer 
from  the  apex,  and  by  repeated  punctures  of  the  thinned  struc- 
ture, brings  about  a  gradual  contraction  and  diminution  of  the 
cone.  This  operation  sets  up  much  less  irritation  than  Von 
Graefe' s,  and  is  equally  effective. 

ARCirs  sz:n-ii.zs 

is  the  term  apphed  to  the  yellow  or  whitish  ring  which  is  often 
seen  round  the  margins  of  the  cornea  in  elderly  persons.     Some- 
times   the    ring   spreads    into 
broad  patches;  sometimes  there  °' 

is  an  indication  of  a  second  and 
smaller  ring.  Fig;.  Ill  was 
drawn  from  such  a  case.  Both 
eyes  were  similarly  affected. 
The  morbid  appearance  is  due, 
as  Mr.  Canton  has  shown,  to  a 
deposit  of  fat.  He  has  fully 
discussed  its  nature,  varieties, 
and  pathological  significance  in 
his  treatise  on  the  subject. 
Its  practical  importance  has 
been  summed  up  by  Sir  James  Paget,  as  follows  :  "  The  arcus 
senilis  seems  to  be,  on  the  whole,  the  best  indication  which  has 
yet  been  found  of  proneness  to  an  extensive  or  general  fatty 
degeneration  of  the  tissues"  (Surgical  Pathology,  Lecture  VI.). 

It  admits  of  no  remedy,  and  does  not  interfere  with  any 
operation  which  it  may  be  necessary  to  perform  upon  the  eye. 

SCIiEROTITIS. 

The  sclerotic  often  participates  in  inflammation  of  the  cornea 
or  of  the  iris,  but  it  may  also  be  primarily  and  chiefly  affected. 
Such  cases  are  sometimes  spoken  of  as  rheumatic  ophthalmia, 
because  the  sclerotic  is  a  fibrous  tissue,  like  those  which  are  the 
chief  seats  of  rheumatism,  and  because  the  inflammation  of  the 
sclerotic  is  often  caused  by  cold  and  wet — the  conditions  which 
lead  to  rheumatism  in  other  parts  of  the  body. 

Sclerotitis  is  a  disease  of  adult  life,  and  is  often  confined  to  one 
eye.  Sight  is  impaired.  There  is  intense  pain  of  an  aching  kind, 
which  is  worse  at  night,  and  which  pervades  the  orbit  and  brow, 
as  well  as  the  eyeball.     The  vessels  of  the  sclerotic  are  seen 


Double  arcus  senilis. 


240  DISEASES   OF  TISSUES  AND  ORGANS. 

radiating  in  straight  lines  round  the  margin  of  the  cornea,  and 
presenting  a  pink  or  violet  hue.  There  is  generally  a  good  deal 
of  fever,  and  there  are  often  rheumatic  pains,  or  symptoms  of 
gout,  in  other  parts.  The  iris  often  participates  in  the  inflam- 
mation. 

Treatment. — The  bowels  should  be  cleared,  and  then  quinine 
or  the  iodide  of  potassium  or  colchicura  should  be  given  (F.  56,  61), 
with  opiates  or  sedatives  at  bedtime  (F.  7,  41,  53). 

Locally,  anodyne  ointments  or  lotions,  and  the  application  of 
dry  heat,  are  the  most  useful  measures.  Blisters  and  leeches 
often  increase  the  neuralgic  pain.  Atropine  should  be  dropped 
into  the  eye  twice  a  day,  both  to  dilate  the  pupil  and  to  act  as 
a  sedative  (F.  6). 

IRITIS 

may  be  excited  by  an  injury,  or  by  an  excessive  use  of  the  eye, 
or  it  may  arise  spontaneously.  In  the  latter  case  it  is  generally 
associated  with  a  rheumatic  or  syphilitic  state  of  the  constitution. 
The  injuries  which  are  most  likely  to  lead  to  iritis  are  blows 
upon  the  eye,  and  wounds  of  the  iris,  especially  when  a  foreign 
body  is  lodged  in  contact  with  it.  A  clean-cut  wound,  such  as 
that  which  is  made  in  iridectomy,  seldom  sets  up  much  inflamma- 
tion. 

Iritis  may  be  either  acute  or  chronic.  When  it  is  dependent 
upon  a  rheumatic  or  syphilitic  taint,  it  is  particularly  apt  to  be- 
come chronic.  Under  any  circumstances,  when  it  has  once 
appeared,  it  is  prone  to  recur. 

General  symptoms. — There  is  a  pink  or  violet  zone  of  vessels 
around  the  margin  of  the  cornea,  as  in  sclerotitis.  The  aqueous 
humour  becomes  muddy  or  yellowish.  The  iris  is  clouded  and 
covered  with  a  film,  so  that  its  structure  cannot  be  distinctly  seen. 
Its  colour  is  altered,  and  it  appears  of  a  dusky  brown,  or  of  a 
greyish  green,  owing  in  some  measure  to  discoloration  of  the 
aqueous  humour.  Its  movements  are  limited  by  the  efiusion  on 
its  surface  and  into  its  substance ;  and  the  pupil  becomes  small 
and  irregular.  There  is  impairment  of  vision,  with  lachrymation 
and  photophobia.  There  is  great  pain  in  the  eyeball,  orbit,  and 
brow.  With  this  there  may  be  more  or  less  inflammation  of  the 
cornea  and  conjunctiva.  There  is  always  a  good  deal  of  consti- 
tutional disturbance. 

Special  symptoms  of  rheumatic  iritis. — The  attack  has  pro- 
bably been  brought  on  by  exposure  to  cold  and  wet.  There  may 
be  a  history  of  rheumatism  or  gout.  The  sclerotic  is  largely  im- 
plicated in  the  inflammation,  and  its  vessels  are  congested,  so 
timt  the  vascular  zone  is  not  sharply  defined.     The  neuralgic 


lEITIS.  241 

pain  in  the  eye  and  brow  is  very  severe,  and  there  is  great  into- 
lerance of  light. 

Special  symptoms  of  syphilitic  iritis. — There  is  a  history  of 
syphilis,  and  often  there  are  some  other  manifestations  of  the 
disease  present  at  the  same  time.  The  effused  lymph  is  not 
spread  over  the  entire  surface  of  the  iris,  but  aggregated  here 
and  there  in  the  form  of  minute  nodules  or  beads.  The  vascular 
zone  is  well  defined.  There  is  generally  less  intolerance  of  light 
than  in  the  rheumatic  variety.  The  pain  remits  during  the  day, 
and  is  worse  at  night. 

Treatment. — The  patient  should  be  confined  to  a  darkened 
room,  or  wear  a  shade.  If  it  seems  advisable,  the  temples  may 
be  cupped  or  leeched.  Under  any  circumstances  the  bowels 
should  be  freely  opened,  and  a  moderately  low  diet  enforced.  The 
pupil  should  be  thoroughly  dilated  with  a  solution  of  atropine 
(gr.  j — ij  ad  ^j).  The  eftusion  of  lymph  may  perhaps  be  pre- 
vented, or  its  absorption  promoted,  by  small  doses  of  mercury, 
stopping  short  of  salivation — for  example,  two  grains  of  calomel 
with  a  quarter  of  a  grain  of  opium,  or  three  grains  of  grey 
powder,  every  four  hours.  Pain  should  be  relieved  by  belladonna 
fomentations;  by  giving  opium,  coniura,  or  henbane;  and  by 
rubbing  anodyne  ointments  into  the  brow. 

Special  treatment  of  rheumatic  iritis. — The  bicarbonate  of 
potass  (F.  56),  or  the  iodide  of  potassium,  or  guaiacura,  or  qui- 
nine (F.  61,  65)  should  be  administered.  If  there  is  a  gouty  habit, 
colchicum  will  be  found  useful.  The  patient  should  not  be  kept 
on  too  low  a  diet.  In  some  cases  he  will  even  require  brandy 
or  other  stimulants  from  the  first. 

Special  treatment  of  syphilitic  iritis. — If  the  patient's  con- 
stitution is  sound,  a  course  of  mercury  by  the  mouth,  or  by  inunc- 
tion, may  be  prescribed,  so  as  slightly  to  afiect  the  gums.  Under 
any  circumstances  the  iodide  of  potassium  may  be  given  (F.  50, 60). 
As  soon  as  the  acute  symptoms  begin  to  yield,  tonics  should  be 
ordered,  and  a  more  liberal  diet  allowed. 

If  iritis  in  any  of  its  forms  threatens  to  become  chronic,  the 
temples  may  be  leeched  from  time  to  time,  and  counter-irritation 
kept  up  by  means  of  iodine  paint,  blisters,  or  setons. 

In  recurrent  iritis,  iridectomy  will  arrest,  or  at  least  lessen, 
the  severity  of  the  attacks.  It  appears  to  act  partly  by  putting 
an  end  to  the  irritation  caused  by  the  adhesions  {synecMce), 
which  are  almost  sure  to  follow  repeated  attacks  of  inflammation, 
and  partly  by  allowing  a  freer  communication  between  the  anterior 
and  posterior  aqueous  chambers. 


242  DISEASES   OF  TISSUES  AND   ORGANS. 


ARTIFICIAIi  PUPIIi. 

When  the  natural  pupil  is  obscured  by  central  opacity  of  the 
cornea,  or  has  become  closed  by  inflammatory  deposits  or  adhe- 
sions, while  the  rest  of  the  cornea  retains  its  transparency,  an 
artificial  pupil  may  sometimes  be  formed,  so  as  to  allow  the  rays 
of  light  to  reach  the  retina. 

The  operation  may  be  performed  in  several  ways.  Generally, 
however,  it  is  done  by  excising  a  portion  of  the  iris  {iridectomy), 
or  by  putting  a  ligature  round  it  (iriddesis).  A  small  incision  is 
made  at  the  margin  of  the  cornea  in  such  a  situation  as  to  allow 
the  iris  to  prolapse,  or  to  be  drawn  gently  out.  This  portion  of 
the  iris  is  then  either  cut  off,  or  included  in  a  ligature  of  fine 
silk,  according  to  the  judgment  of  the  surgeon. 

In  cases  of  closed  pupil  after  the  extraction  of  cataract,  a 
broad  needle  may  be  introduced  through  the  cornea,  and  the 
fibres  of  the  iris  torn  through,  or  divided,  until  a  sufficient 
aperture  has  been  made. 

CATARACT 

signifies  an  opacity  of  the  lens  or  its  capsule.  When  the  lens 
alone  is  affected,  it  is  said  to  be  lenticular ;  when  the  capsule 
alone  is  affected,  it  is  said  to  be  capsular.  Generally,  however, 
both  are  more  or  less  implicated  in  the  disease. 

It  may  be  a  congenital  defect,  or  it  may  be  traumatic,  and  re- 
sult from  the  inflammation  which  has  been  excited  by  an  injury, 
or  even  from  the  shock  of  a  blow  which  leaves  no  external  mark. 
Most  frequently,  however,  it  comes  on  gradually  with  old  age, 
and  is  one  of  the  many  manifestations  of  the  degeneration  which 
the  body  is  apt  to  undergo  as  life  advances.  The  proper  tissue  of 
the  lens  seems  to  become  opaque  and  atrophied,  while  there  is  a 
deposit  of  fatty  and  earthy  matter  in  the  more  superficial 
parts. 

Symptoms. — Vision  is  impaired,  the  sight  becoming  progres- 
sively worse  as  the  disease  advances.  The  patient  can  generally 
see  best  in  twilight,  or  when  his  back  is  turned  to  the  window, 
because  then  the  iris  expands,  and  allows  the  marginal  rays  to 
reach  the  retina.  The  eye  presents  a  dull  appearance,  and  on 
examining  it  closely,  the  lens  is  seen  to  be  of  a  pearly-white  or  of 
a  yellowish  colour. 

Cataracts  are  broadly  divided  into  hard  and  soft. 

The  hard  cataract  is  met  with  in  middle-aged  and  elderly  per- 
sons. It  has  a  yellowish  or  brownish  tint.  The  opacity  may  be 
greatest  at  the  centre,  and  then   the  patient  can    see  best  when 


CATAEACT.  243 

the  pupil  is  dilated  by  atropine  or  otherwise ;  but  sometimes  the 
circumference  of  the  lens  is  chiefly  afiected. 

The  soft  cataract  is  a  disease  of  the  young  or  middle-aged,  and 
is  not  unfrequently  congenital.  It  has  a  white  milky  colour. 
The  lens  is  enlarged,  and  vision  is  much,  and  uniformly,  impaired. 
In  the  congenital  form,  however,  the  opacity  may  be  confined  to 
the  central  parts  of  the  lens,  and  remain  for  many  years  without 
extending  to  the  margins. 

The  treatment  consists  in  removing  the  lens  by  operation. 
Medicine  has  no  power  to  arrest  the  progress  of  the  disease,  or 
to  procure  its  absorption. 

The  lens  may  be  removed  in  several  ways — (1)  by  extraction, 
(2)  by  depressing  it  below  the  axis  of  vision  (couching),  (3)  by 
breaking  it  up,  and  leaving  it  to  be  absorbed  (solution),  (4)  by 
removing  the  lenticular  matter  through  a  small  aperture  in  the 
cornea  (linear  extraction). 

1.  Extraction  is  performed  by  making  an  incision  through  half 
of  the  circumference  of  the  cornea,  opening  the  capsule,  and 
allowing  the  lens  to  escape  entire  through  the  pupil. 

A  method  of  extraction,  known  as  Von  Graefe's  operation,  is 
much  practised  at  the  present  time.  The  incision  is  made  with  a 
long  narrow  knife  just  within  the  corneal  margin,  occupying  about 
one-third  of  the  circumference ;  a  piece  of  iris  is  removed,  the  cap- 
sule torn,  and  the  lens  pressed  out,  as  in  ordinary  extraction.  By 
this  operation  all  risk  of  prolapse  of  the  iris,  which  is  so  common 
after  the  usual  operation,  is  avoided.  The  recovery  of  the  eye, 
too,  seems  to  be  more  rapid.  If  the  iridectomy  is  made  upwards, 
the  irregularity  of  the  pupil  is  hidden  by  the  upper  lid,  and  the 
sharpness  of  vision  does  not  appear  to  be  diminished. 

If  all  goes  on  well,  the  wound  is  healed  by  the  end  of  a  week 
or  ten  days,  but  the  eye  will  require  protection  and  rest  for  a 
considerable  time.  The  patient  should  not  be  allowed  to  use  the 
glass,  which  will  be  necessary  for  accurate  vision,  for  at  least  three 
or  four  months. 

2.  The  operation  of  couching  consists,  as  we  have  said,  in 
depressing  the  lens  below  the  line  of  vision.  By  the  aid  of  a 
couple  of  needles  it  is  lodged  in  the  vitreous  humour,  behind  the 
ciliary  processes,  and  gradually  undergoes  absorption. 

Couching  is  an  operation  which  is  very  seldom  performed  at  the 
present  day.  It  is  rough  in  execution,  and  apt  to  excite  serious 
inflammation,  with  perhaps  the  ultimate  loss  of  vision. 

3.  Solution  is  a  method  of  treatment  particularly  applicable  to 
the  softer  varieties  of  cataract.  One  or  two  needles  are  intro- 
duced near  the  margin  of  the  cornea,  and  the  anterior  capsule  of 
the  lens  is  torn  through,  so  that  the  aqueous  humour  comes  in  cou- 

E  2 


244  DISEASES  OF  TISSUES  AND   OEGANS. 

tact  with  the  lenticular  substance.  Absorption  then  takes  place. 
The  operation  may  have  to  be  repeated  two  or  three  times  before 
the  whole  of  the  cataract  has  been  absorbed.  On  this  account, 
the  process  is  rather  a  tedious  one. 

4.  Linear  extraction  is  a  modern  improvement  on  the  fore- 
going. After  the  capsule  has  been  ruptured,  either  at  once  or 
after  a  few  days'  interval,  the  soft  lenticular  matter  is  stirred  up, 
a  curette  is  introduced  through  a  suitable  puncture  in  the  cornea, 
and  the  whole,  or  the  greater  part,  of  the  lens  is  removed. 

Before  solution  is  undertaken,  the  pupil  should  be  dilated  with 
atropine ;  and  it  should  be  kept  dilated  until  entire  absorption  has 
taken  place.  It  is  often  beneficial  to  support  the  eye  by  a  light 
pad  of  cotton-wool  and  a  bandage.  Where  only  a  small  corneal 
wound  has  been  made  a  thin  piece  of  wet  linen,  laid  over  the  eye, 
is  all  that  will  be  required. 

In  every  case  in  which  the  lens  has  been  taken  away  the  patient 
will  have  to  use  a  convex  glass  to  correct  the  refraction. 

GIiilUCOMA 

is  a  disease  which  has  attracted  a  great  deal  of  attention  of  late 
years.  Though  it  has  been  very  carefully  studied,  its  pathology 
is  not  yet  satisfactorily  explained.  It  seems  to  depend  upon 
intra-ocular  pressure,  which  first  palsies  the  retina,  and  then 
gradually  disorganizes  the  other  structures  of  the  eye. 

The  disease  is  now  usually  divided  into  the  infiammatory  and 
the  non-inflammatory  varieties.  The  inflammatory  cases  are 
further  subdivided  into  acute  and  chronic. 

Acute  glaucoma  is  generally  preceded  by  a  premonitory  stage, 
during  which  the  patient  is  liable  to  occasional  attacks,  attended 
with  increased  hardness  (tension)  of  the  eyeball,  congestion  of  the 
vessels,  dimness  of  sight,  and  pain  in  and  around  the  eye.  There 
is  increasing  presbyopia,  and  contraction  of  the  visual  field.  When 
the  patient  looks  at  a  lighted  candle,  he  sees  a  halo  or  rainbow 
around  the  flame.  These  attacks  become  more  frequent,  till  at  last 
the  patient  is  suddenly  seized  with  great  pain  in  the  eye  and  neigh- 
bouring parts,  with  feverishness  and  sickness.  The  eye  is  found 
to  be  very  liard,  the  lids  swollen,  the  conjunctiva  inflamed,  the 
pupil  dilated,  the  anterior  chamber  shallow,  and  the  cornea  hazy. 
Vision  is  impaired  or  destroyed,  and  there  are  flashes  or  stars  of 
light  before  the  eyes.  Generally  the  humours  are  so  cloudy  that 
an  ophthalmoscopic  examination  cannot  be  made. 

The  attack  may  yield  to  treatment,  or  it  may  subside  spon- 
taneously, and  the  patient  may  recover  a  portion  or  the  whole  of 
his  sight.  But  after  a  time  it  recurs,  and  the  vision  is  either 
irreparably  lost,  or  the  inflammation  passes  into  the  chronic  form. 


GLAUCOMA.  245 

Chronic  glaucoma  may  follow  an  acute  attack,  or  it  may  be 
gradually  developed  from  the  premonitory  stage.  The  eye  remains 
hard,  the  field  of  vision  is  contracted,  there  is  dimness  of  sight,  there 
are  motes  before  the  eyes  by  day  and  flashes  or  sparks  by  night,  the 
pupil  is  dilated  and  sluggish,  there  are  frequent  attacks  of  pain, 
the  conjunctiva  is  congested,  and  there  are  large  tortuous  veins  on 
the  sclerotic,  the  cornea  becomes  rough,  hazy,  and  callous,  and  the 
humours  become  turbid.  If  an  ophthalmoscopic  examination  can  be 
made,  the  retinal  veins  are  seen  to  be  dilated  and  tortuous,  while 
the  arteries  are  small  and  pulsating,  and  the  optic  nerve  is 
cupped,  or  hollowed  out,  from  the  continued  intra-ocular 
pressure.  Spots  of  haemorrhage  are  also  often  visible  about  the 
fundus. 

Non-inflammatory  or  simple  glaucoma  comes  on  so  gradually 
that  it  often  passes  unnoticed,  until  the  patient  suddenly  finds  that 
he  has  lost  the  sight  of  one  eye.  The  eye  may  look  quite  healthy, the 
media  may  be  clear,  and  the  movements  of  the  iris  may  be  normal. 
There  is  generally,  however,  increased  hardness  of  the  eyeball,  and 
on  an  ophthalmoscopic  examination,  the  optic  nerve  is  found  to  be 
cupped,  with  dilated  retinal  veins  and  pulsating  arteries.  The 
sight  gradually  fails,  and  the  field  of  vision  becomes  contracted. 

The  disease  may  thus  advance  painlessly  to  blindness ;  but  it 
more  frequently  takes,  after  a  time,  the  characters  of  the  acute  or 
chronic  infiammation,  and  presents  the  symptoms  which  have 
been  already  described  in  speaking  of  those  varieties. 

Glaucoma  may  also  follow  various  affections  or  injuries  of  the 
eye,  as  choroiditis  or  traumatic  cataract. 

It  is  then  termed  secondary.  For  details  of  these  varieties,  the 
reader  may  be  referred  to  Mr.  Soelberg  Wells's  or  to  Mr. 
Lawson's  works  on  the  Diseases  of  the  Eye. 

Treatment. — Medical  treatment  is  of  little  avail  in  any  of  the 
various  forms  of  glaucoma.  The  immediate  inflammation  and 
pain  may  be  relieved  by  mercury,  opium,  leeches,  fomentations, 
&c.,  but  the  eye  is  not  cured.  A  solution  of  eserine  (gr.  i  ad  ^i), 
dropped  into  the  affected  eye  two  or  three  times  a  day,  seems 
sometimes  to  lessen  the  undue  tension.  Sooner  or  later  the  disease 
will  again  show  itself,  perhaps  more  acutely  than  before. 

Several  operative  measures  have  been  adopted  for  the  relief  of 
this  affection. 

Paracentesis  of  the  anterior  chamber  is  of  value  in  relieving 
the  immediate  symptoms,  and,  if  it  is  frequently  repeated,  it  may 
arrest  the  disease  for  a  time. 

Mr.  Hancock  recommends  the  division  of  the  ciliary  muscle. 

In  1856,  the  late  Professor  von  Graefe,  of  Berlin,  introduced 
the  method  of  treating  glaucomatous  affections  by  the  removal 


246  DISEASES   OF  TISSUES  AND   OEGANS. 

of  a  portion  of  the  iris  {iridectomy).  This  measure  has  been  ex- 
tensively practised  in  this  country,  and  is,, indeed,  almost  the  only 
operation  now  employed  in  this  disease.  Its  eflScacy  depends  much 
ou  the  removal  of  a  large  piece  of  iris,  and  on  its  being  torn 
away  quite  up  to  the  ciliary  margin. 

AMAUROSIS. 

The  term  amaurosis  used  to  be  employed  to  denote  dimness,  or 
loss  of  sight,  from  causes  unexplained  by  the  external  appearance 
of  the  eye,  and  which  was  attributed  to  disease  of  the  retina,  optic 
nerve,  or  brain.  But,  since  the  introduction  of  the  ophthal- 
moscope, our  knowledge  of  the  diseases  affecting  the  deeper 
structures  of  the  eye  has  made  great  progress.  Many  of  the 
cases  which  were  formerly  called  amaurosis  have  been  classified 
under  other  heads,  and  the  term  is  now,  by  common  consent,  con- 
fined to  blindness  depending  upon  cerebral  or  cerebro-spiual  causes. 
Thus  it  includes  most  of  the  examples  of  atrophy  of  the  optic  nerve. 

The  most  frequent  cerebral  causes  of  amaurosis  are  tumours, 
syphilitic  deposits,  blood  clots,  hydrocephalus,  meningitis,  and  em- 
bolism ;  while  the  most  frequent  spinal  cause  is  locomotor  ataxia. 

The  prognosis  in  all  these  cases  is  unfavourable — indeed,  it  is 
only  when  the  disease  is  of  syphilitic  origin,  or  when  it  depends 
upon  general  ansemia,  or  uterine  derangement,  that  medicine  can 
be  of  much  avail. 

FOBEIGM-    BODIES     ON"   THE    COirJVM'CTIVA   OB 

COBIO-EA. 

Foreign  bodies,  such  as  eyelashes,  particles  of  dust,  &c.,  often 
adhere  to  the  conjunctival  surface,  and  give  rise  to  great  uneasi- 
ness. If  they  are  not  removed,  they  may  even  produce  a  consi- 
derable amount  of  inflammation.  They  are  generally  situated 
just  above  the  margin  of  the  upper  lid.  To  remove  them  from 
this  position  the  lid  must  be  everted.  This  is  done  by  laying  a 
probe  across  the  upper  lid  about  half  an  inch  from  its  margin. 
The  central  eyelashes  are  then  taken  between  the  finger  and 
thumb  of  the  other  hand,  and  drawn  outwards,  whilst  the  probe  is 
gently  pressed  upon  the  lid,  and  the  patient  is  told  to  look  down- 
wards. By  this  means  the  tarsal  cartilage  will  tilt  over,  and 
expose  the  conjunctival  surface.  The  foreign  body  may  then 
be  removed  with  a  camel's-hair  brush,  a  feather,  or  a  "  spud." 
If  the  particle  is  embedded  in  the  conjunctiva,  it  may  be  lifted 
out  with  a  broad  needle.  Or  the  conjunctiva  may  be  raised  with 
a  small  pair  of  forceps,  and  the  piece,  in  which  the  foreign  body 
is  embedded,  snipped  off  with  scissors.  The  trifling  cicatrix  thus 
made  soon  heals,  and  leaves  no  trace  behind  it. 


TUMOURS   OF  THE  EYEBALL. 


247 


Particles  imbedded  in  the  cornea  are  held  so  tight  by  the 
elastic  structure  that  they  are  often  difficult  to  remove.  They 
consist  generally  of  sharp  fragments  of  metal,  sand,  or  coal. 

In  order  to  extract  them,  the  patient  should  be  directed  to  fix 
his  eye  on  some  convenient  point,  and  then,  the  globe  being 
steadied,  the  particle  may  be  picked  out  with  a  "  spud,"  or  with 
the  point  of  a  cataract  knife. 

If  the  particle  is  deeply  embedded,  or  if  the  patient  is  unable  to 
control  the  movements  of  the  eye,  it  may  be  necessary  to  give 
chloroform  before  extraction  will  be  possible. 

"WOUUDS    OF   THE  EVEBAIil^. 

If  the  globe  is  simply  wounded,  the  best  thing  that  can  be 
done  is  to  close  the  lids,  fix  them  with  a  strip  of  plaster,  and  give 
firm  support  to  the  eye  by  means  of  a  pad  of  cotton-wool  and  a 
bandage.  Should  inflammation  arise,  it  must  be  treated  by  the 
ordinary  measures — leeches,  fomentations,  &c. 

When  the  eyeball  has  been  wounded,  and  a  foreign  body  lodged 
in  it,  an  attempt  should  be  made  to  remove  the  extraneous  substance 
at  once.  If  this  is  not  done,  it  may  set  up  suppurative  inflamma- 
tion, and  lead  to  the  destruction  of  the  eye.  After  the  removal 
of  the  foreign  body,  the  case  must  be  treated  as  a  simple  wound. 

TUMOURS  OF  THE  EYEBAI.I. 


are  generally  malignant  in  their  nature, 
apt  to  be  attacked  by  medullary 
sarcoma,  or  rather  by  that  variety 
of  it,  the  small  round-celled  sarcoma, 
known  as  glioma.  The  disease  appears 
to  spring  from  the  retina  or  choroid. 
It  growls  rapidly,  fills  the  globe,  bursts 
the  tunics,  and  then  protrudes  between 
the  lids  in  a  fungous  mass.  Fig.  113 
was  drawn  from  a  little  boy,  aged  V, 
who  was  Mr.  Bowman's  patient.  The 
tumour  had  been  growing  about  six 
weeks,  and  was  of  the  size  and  shape 
of  a  small  orange. 

In  later  life  the  choroid  often 
becomes  the  seat  of  melanotic  cancer. 
The  disease  advances  very  slowly.  It 
may,  however,  be  easily  detected  in  its 
early  stage  by  the  ophthalmoscope. 

In  children  scrofulous  deposits  in 
the  deep  structures  of  the  eye  are  not 


In  early  life  the  eye  is 
Fig.  112. 


Medullary  tumour  of 
the  eyeball. 


248  DISEASES  OF  TISSUES  AND  ORGANS. 

uncommon,  and  produce  equally  destructive  results,  as  far  as  the 
eye  is  concerned. 

Treatment. — In  any  case  the  only  remedy  is  the  extirpation  of 
the  eyeball.  This  is  done  by  slitting  up  the  ocular  conjunctiva 
around  the  globe,  and  dividing  each  of  the  tendons  in  turn.  The 
eye  is  then  drawn  gently  forwards,  and  the  optic  nerve  cut  with 
a  pair  of  curved  scissors.  The  bleeding  should  be  arrested  by  a 
stream  of  cold  water ;  a  fold  of  wet  lint  should  be  laid  over 
the  orbit,  and  perfect  rest  enjoined  for  some  days. 

SQUIITTIirG, 

or  strabismus,  may  be  defined  to  be  a  want  of  parallelism  between 
the  visual  axes  of  the  eyes.  If  the  lines  of  sight  converge,  the 
squint  is  said  to  be  convergent ;  if  they  diverge,  it  is  said  to  be 
divergent. 

When  only  one  eye  is  affected,  the  squint  is  said  to  be  single. 
When  the  obliquity  is    observable  in  both  eyes,    it    is  termed 


Squinting  depends  upon  a  want  of  equilibrium  between  the 
opposing  muscles  of  the  eyeball.  This  want  of  equilibrium  may 
be  congenital,  or  it  may  come  on  at  any  period  of  life.  The 
causes  which  give  rise  to  it  are  numerous.  Sometimes  it 
follows  the  irritation  of  teething,  or  of  worms.  Sometimes  it 
is  a  sequela  of  fever,  or  of  exanthematous  disease.  Sometimes 
it  arises  from  weakness  of  one  eye,  and  consequent  want  of  use. 
Sometimes  it  depends  upon  defective  vision,  such  as  myopia, 
or  hypermetropia.  Sometimes  a  nebula  on  the  cornea  leads 
the  patient  to  use  his  eye  obliquely.  Sometimes  it  is  asso- 
ciated with  hydrocephalus,  convulsions,  or  compression  of  the 
brain. 

The  treatment  necessarily  varies  with  the  cause.  When  the 
squint  depends  upon  organic  disease  of  the  brain,  nothing  can  be 
done  to  remedy  it.  When  it  is  a  symptom  of  compression,  we 
must  endeavour  to  remove  the  compressing  force.  When  it  is 
due  to  irritation,  it  may  be  relieved  by  judicious  medical  treat- 
ment. But  when  it  is  congenital,  or  has  existed  for  a  long 
time,  when  the  eyesight  is  unimpaired,  and  when  there  is  no 
disease  of  the  brain  or  retina,  an  operation  should  be  recom- 
mended. The  tendon  of  the  preponderating  muscle  should  be 
divided,  close  to  its  insertion  into  the  globe.  If  the  squint  is 
convergent,  the  internal  rectus  will  have  to  be  cut;  if  the 
obliquity  is  outwards,  the  external  rectus  must  be  divided. 

The  patient  being  anaesthetized,  the  conjunctiva  at  the  lower 
margin  of  the  tendon,  near  its  insertion,  is  raised  with  a  forceps, 
and  snipped  with  a  pair  of  blunt-pointed  scissors ;  a  blunt  hook 


POLYPUS   OF  THE  EAE.  249 

is  then  passed  under  the  tendon,  which  is  next  divided  subcon- 
junctivally  with  the  scissors.  Sometimes  a  second  opening  is 
made  in  the  conjunctiva  at  the  upper  border  of  the  tendon  to 
allow  the  eiFused  blood  to  escape. 

ACCUlVIUIiATION-   OF  "WAX   Xir   THE  EAR. 

Not  unfrequently  the  wax,  mixed  with  hairs  and  epithelium, 
collects  in  hard,  dark-brown  masses  in  the  external  meatus. 
When  this  happens,  it  gives  rise  to  crackling  and  singing  noises 
in  the  ears,  deafness,  and  perhaps  giddiness. 

The  treatment  consists  in  dropping  a  little  oil,  or  glycerine, 
into  the  ears  every  night,  and  syringing  them  gently,  but 
efficiently,  every  morning  with  warm  water,  until  all  the  super- 
fluous wax  has  been  removed.  In  syringing  the  ear  the  helix 
should  be  drawn  gently  upwards  and  outwards  so  as  to 
straighten  the  canal ;  and  the  stream  should  be  directed  rather 
along  its  upper  wall.  The  accumulation  of  wax  seems  often  to 
be  associated  with  other  defects  of  the  ear,  for  Toynbee  found 
that  in  60  cases  only  out  of  165  did  the  removal  of  cerumen 
restore  normal  hearing. 

OTORRHCEA 

is  the  name  given  to  a  purulent,  or  muco-purulent,  discharge 
from  the  ear.  It  may  arise  either  from  inflammation  of  the  ex- 
ternal meatus,  from  polypus,  or  from  disease  of  the  internal  ear. 
The  first  variety  is  often  seen  in  scrofulous  children ;  the  last  is  a 
frequent  consequence  of  scarlatina. 

Treatment. — In  the  first  case  the  meatus  should  be  syringed 
with  warm  water,  or  with  astringent  lotions,  while  attention  is 
paid  to  the  general  health.  The  syringing  should  be  done  with 
great  care  :  to  a  sensitive  and  delicate  organ  like  the  ear  a  forcible 
stream  of  water  is  not  so  harmless  as  some  suppose.  If  the 
disease  is  situated  in  the  inner  ear,  and  the  tympanum  is  per- 
forated, the  case  is  much  more  serious.  There  is  danger  of 
meningitis,  or  abscess  of  the  brain,  or  phlebitis,  or  other  com- 
plications. During  the  acute  stage,  the  treatment  must  be 
active — leeches  behind  the  ear,  fomentations,  purgatives,  and 
salines.  Afterwards  a  course  of  tonics  will  be  very  beneficial,  and 
the  impairment  of  hearing,  which  is  sure  to  follow,  may  be 
remedied  by  an  artificial  tympanum. 

POX.YPVS   OF   THE   EAR. 

The  polypi  which  are  met  with  in  the  ear  are  sometimes  of  a 
solid  fibrous  consistence  and  bright  red  colour;  at  other  times 
they  are  pale  pink  and  gelatinous.     Sometimes  they  are  attached 


250  DISEASES    OF  TISSUES  AND  ORGANS. 

by  a  broad  base  to  the  side  of  the  meatus  ;  sometimes  by  a  narrow 
pedicle ;  in  some  instances  they  even  spring  from  the  membrana 
tympani.  They  are  accompanied  by  a  muco-pnrulent  discharge. 
The  treatment  consists  in  removing  them  by  a  polypus-forceps, 
or  scissors,  and  touching  the  spot  from  which  they  grew  with  a 
fine  pencil  of  lunar  caustic. 

FOREIGN'   BODIES  IIT  THE  EAR. 

Foreign  bodies,  such  as  peas,  beads,  pebbles,  insects,  &c.,  are 
sometimes  lodged  in  the  ear,  and  cause  great  anxiety  and  alarm. 

In  such  a  case  the  first  thing  to  be  done  is  to  examine  the  ear, 
and  make  sure  that  there  really  is  a  foreign  body  present,  as  well 
as  to  ascertain  its  size  and  situation.  This  may  be  done  by 
throwing  light  into  the  ear  through  an  ear  speculum,  or  a  cone 
of  white  paper. 

The  ear  should  then  be  syringed  with  warm  water,  the  stream 
being  directed  along  the  upper  wall  of  the  meatus.  If  this  fails, 
a  loop  of  fine  wire  may  perhaps  be  passed  round  the  foreign  body, 
or  a  suitable  scoop  or  forceps  may  be  tried ;  but  such  instruments 
must  be  used  with  great  caution.  If  these  means  fail,  it  is  better 
to  leave  it  to  make  its  own  way  out.  Force  should  on  no  account 
be  used;  it  is  most  dangerous. 

EPISTAXIS, 

or  bleeding  from  the  nose,  may  be  the  result  of  an  operation  or 
an  injury ;  or  it  may  depend  upon  plethora  and  active  congestion, 
or  upon  passive  congestion  with  disease  of  the  heart  or  lungs,  or 
upon  a  medullary  growth  within  the  nose,  or  upon  an  impoverished 
state  of  the  blood,  arising  from  general  debility',  scurvy,  or  fever  j 
or  it  may  arise  from  various  other  causes. 

If  the  haemorrhage  occurs  in  a  plethoric  person  of  middle  age, 
who  is  subject  to  giddiness,  or  other  cerebral  symptoms,  or  if  it 
seems  to  be  associated  with  inflammation  of  some  adjacent  part, 
we  must  not  be  in  too  great  a  hurry  to  arrest  it. 

But  if  the  bleeding  arises  from  an  operation  or  an  injury,  or 
if  it  depends  upon  disease  of  the  heart  or  lungs  or  general  system, 
then  we  must  take  means  for  stopping  it.  The  patient's  head 
should  be  elevated,  and  his  nose  well  bathed  with  cold  water.  By 
these  simple  means  the  bleeding  which  so  often  occurs  in  children 
may  generally  be  stopped.  If  more  active  measures  are  needed, 
a  bag  of  ice  should  be  held  to  his  forehead ;  he  should  snuff  up 
powdered  matico  or  gall-nuts  or  tannic  acid ;  styptics — solution 
of  alum  or  of  the  perch loride  of  iron — should  be  injected  into  the 
nostril;  a  continuous  stream  of  iced  salt  and  water  should  be 
directed  through  the  nostrils  by  means  of  a  syphon  tube ;  or  the 


LIPOMA.  251 

anterior  nares  should  be  plugged  with  strips  of  lint,  dipped, 
if  need  be,  in  the  muriated  tincture  of  iron.  If  all  these  measures 
fail,  the  posterior  orifice  must  be  closed  as  well. 

Plugging  the  posterior  nares. — This  is  done  by  arming  a 
catheter,  or  an  elastic  bougie,  or  the  instrument  made  for  the 
purpose  (Bellocq's  cauula).  Fig.  113,  with  a  fiine  twine,  and  then 


Bellocq's  canula. 

passing  it  along  the  floor  of  the  nose,  and  making  the  point 
project  below  the  soft  palate.  A  forceps  is  then  introduced  into 
the  pharynx,  the  twine  is  seized,  and  one  end  of  it  is  brought  out 
at  the  mouth.  The  instrument  is  then  withdrawn  from  the 
nose,  leaving  the  twine  as  before.  We  have  thus  got  a  ligature 
passing  along  the  floor  of  the  nose,  through  the  posterior  nares, 
looped  round  the  soft  palate,  and  emerging  at  the  mouth.  A 
small  roll  of  lint,  or  a  piece  of  sponge  of  suitable  size,  is  next 
attached  to  the  lower  ligature,  twelve  or  fifteen  inches  from  the 
end  of  it.  By  gently  pulling  the  upper  or  nasal  ligature,  the 
plug  of  lint  or  sponge  is  drawn  into  the  mouth,  behind  the  soft 
palate,  and  into  the  posterior  nares.  Both  the  ligatures  should 
then  be  secured,  and  the  plug  allowed  to  remain  for  two  or  three 
days — in  fact,  until  it  becomes  loose. 

Sometimes  it  is  necessary  to  plug  the  anterior  as  well  as  the 
posterior  nares,  in  which  case  the  string  that  projects  from  the 
nostril  may  be  used  to  secure  the  anterior  plug. 

While  these  mechanical  means  are  used,  gallic  acid  or  turpen- 
tine or  other  styptics  should  be  administered  internally  (F.  29). 

IiZPOIVIA 

is  the  name  given  to  tumours  which  are  sometimes  seen  on  the 
external  surface  of  the  nose.  The  tip  becomes  bulbous,  and 
gradually  enlarges,  until  one  or  more  round,  pendulous  masses  are 
formed.  They  consist  of  an  hypertrophy  of  the  skin,  subcuta- 
neous areolar  tissue,  and  fat.  Indeed,  they  are  merely  fatty 
tumours  whose  character  is  somewhat  modified  by  their  situation. 
The  skin  appears  coarse,  the  sebaceous  glands  become  distinct. 


252  DISEASES  OF  TISSUES  AND  ORGANS. 

the  vessels  are  prominent,  and  the  tumour  has  a  purple  or  livid 
colour.  Altogether  it  is  very  unsightly,  and  gives  rise  to  great 
inconvenience. 

Treatment. — During  the  earlier  stages  it  may  be  bathed  with 
stimulating  or  astringent  lotions :  but  when  it  attains  such  a  size 
as  to  interfere  with  the  uses  of  the  nose  or  mouth,  it  should  be 
removed  with  the  knife. 

POIiYPUS  OF  THE  NOSE. 

The  polypi  which  are  met  with  in  the  nose  are  of  two  kinds — 
1,  gelatinous;  2,  fibrous. 

1.  The  gelatinous  polypi  consist  of  an  expansion  of  the  ele- 
ments of  the  mucous  membrane  and  submucous  tissue.  They  are 
generally  multiple,  pear-shaped,  and  grow  rapidly.  They  almost 
always  spring  from  the  outer  wall  of  the  nasal  cavity,  and  are 
most  frequently  connected  with  the  superior  turbinated  bone. 
In  rare  instances  they  are  situated  on  the  septum. 

2.  The  fibrous  polypus  springs  from  the  periosteum,  and  is 
often  connected  with  the  sphenoid  bone,  or  the  basilar  process 
of  the  occipital.  It  is  usually  single,  attached  by  a  broad  base, 
and  grows  slowly.  Its  texture  is  fibrous,  or  fibro-cellular.  It 
is  very  prone  to  degenerate,  and  to  assume  a  malignant 
character. 

Symptoms. — Discharge  from  the  nose;  the  Schneiderian  mem- 
brane is  thickened  and  congested,  especially  in  damp  weather ; 
breathing  is  impeded ;  smell  is  impaired ;  the  voice  is  altered ; 
there  may  be  deafness,  and  sometimes  even  cerebral  symptoms. 
The  tumour  may  be  seen  by  throwing  light  into  the  nostril,  or  by 
using  the  laryngoscope  to  examine  the  posterior  nares ;  or  it  may 
have  advanced  so  far  as  to  have  produced  outward  deformity 
of  the  nose. 

Treatment. — Tonics  and  astringent  lotions  may  be  tried  at 
first,  but  they  seldom  effect  a  cure.  Mr.  Bryant  speaks  highly 
of  the  value  of  tannin  as  a  snuff".  If  these  measures  fail,  the 
growth  must  he  removed,  either  by  the  small  ecraseur,  the 
polypus  forceps,  or  the  ligature. 

The  patient  should  be  seated  in  a  low  chair,  with  his  head 
thrown  back.  The  ecraseur,  with  the  loop  of  fine  wire  projecting 
from  it,  is  passed  along  the  septum,  then  half  turned,  so  that  the 
loop  may  slip  over  the  polypus  to  its  pedicle,  and  the  noose  drawn 
tight.  If  forceps  are  used,  they  are  introduced  closed,  slowly 
opened,  the  polypus  seized,  and  twisted  from  its  attachment. 
This  process  may  be  repeated  until  the  nostril  is  entirely 
cleared.  This  method  of  treatment  is  best  suited  to  the  gela- 
tinous polypus. 


OZ^NA.  253 

The  ligature  is  more  applicable  to  the  fibrous  growth.  A 
noose  of  twine  is  passed  through  the  nose,  by  means  of  a  double 
canula  or  elastic  catheter,  looped  around  the  tumour,  and  then 
tied  tight. 

The  removal  of  a  fibrous  polypus  often  requires  great  in- 
genuity and  dexterity. 

CAirCER  OF  TBE  ITASAIi  CAVITV. 

Besides  the  degenerated  fibrous  polypus,  which,  as  we  have 
said,  often  assumes  a  malignant  character,  the  nasal  cavities  are 
sometimes  the  seat  of  medullary  cancer.  This  disease  is  not 
unfrequently  met  with  in  children.  It  may  either  originate  in 
the  nose,  or  spread  to  it  from  the  antrum.  It  grows  rapidly, 
expands  the  nasal  bones,  protrudes  the  eyeball,  and  gives  rise  to 
great  deformity.  It  is  attended  by  a  profuse  and  offensive  dis- 
charge, causes  severe  and  distressing  pain,  and  generally  proves 
rapidly  fatal  by  involving  the  brain,  or  by  profuse  haemorrhage, 
or  by  exhaustion. 

Treatment. — The  only  treatment  is  extirpation,  and  even  this, 
at  the  best,  is  not  likely  to  do  more  than  prolong  life  for  a  sbort 
time. 

is  the  name  given  to  a  discharge  from  the  nostrils  of  a  peculiarly 
foetid  and  offensive  nature.  It  manifests  itself  in  persons  of  a 
scrofulous  habit,  or  it  may  arise  from  syphilis,  either  inherited  or 
acquired.  The  discharge  is  probably  unnatural  in  character,  and 
rapidly  decomposes  when  it  is  retained  in  the  nasal  cavity. 

In  some  cases  there  is  simply  a  thickened  and  unhealthy  state 
of  the  mucous  membrane;  in  other  cases  there  is  ulceration  ;  and 
sometimes  even  the  bones  are  affected. 

Treatment. — The  first  thing  is  to  examine  the  nose  by  reflected 
light,  and  to  ascertain,  as  far  as  possible,  the  state  of  the  mucous 
membrane,  and  the  source  of  the  discharge.  It  may  depend  upon 
the  presence  of  a  polypus,  or  of  a  foreign  body.  If  the  lining 
membrane  is  congested,  thickened  or  ulcerated,  the  nose  should 
be  frequently  steamed,  and  syringed  with  astringent,  stimulant, 
or  disinfectant  lotions  (F.  17,  27,  12),  and  the  ulcerated  spots 
touched  with  a  solution  of  nitrate  of  silver  or  with  a  pencil  of  the 
solid  caustic.  Nothing  is  better,  as  a  wash,  than  a  liberal  use 
of  warm  water,  to  which  a  little  common  salt  or  Condy's  fluid  or 
chloride  of  lime  has  been  added.  The  best  way  of  using  it  is 
with  Dr.  Thudichum's  nostril  douche  or  with  the  syphon  tube. 
The  patient  should  hold  his  head  over  a  bason,  and  open  his 
mouth  wide.     This  causes  the  soft  palate  to  close  the  posterior 


254  DISEASES  OF  TISSUES   AND  ORGANS. 

nares.  Then  the  tube  should  be  directed  up  one  nostril,  and  the 
return  current  will  soon  begin  to  flow  down  the  other.  Thus 
the  whole  nasal  cavity  will  be  effectually  washed  out.  Under  any 
circumstances,  it  is  of  the  greatest  importance  to  study  the 
general  health,  particularly  if  there  is  a  strumous  tendency  or  a 
syphilitic  taint. 

ABSCESS   OF  THB  AITTRVM. 

The  lining  membrane  of  the  antrum  is  liable  to  become  in- 
flamed from  injury,  or  from  the  irritation  of  carious  teeth,  or 
from  other  causes.  Such  inflammation  is  very  prone  to  run  on  to" 
suppuration. 

Symptoms. — There  is  severe,  deep-seated,  throbbing  pain  in 
the  part,  and  the  soft  tissues  become  swollen  and  tender.  There 
is  a  good  deal  of  constitutional  disturbance.  If  relief  is  not 
afforded,  the  walls  of  the  cavity  become  distended,  the  nose  is 
obstructed,  and  the  face  becomes  deformed. 

The  treatment  consists  in  allaying  inflammation  by  local  and 
constitutional  measures,  in  the  hope  of  anticipating  suppuration. 
When  pus  has  been  formed,  it  sometimes  escapes  through  the 
nose  or  inside  the  upper  lip,  above  the  gum.  Much  more 
frequently,  however,  an  opening  has  to  be  made  into  the  antrum, 
to  give  vent  to  the  matter.  This  may  be  done  either  by  extracting  a 
tooth,  and  pushing  a  trochar  through  its  socket  into  the  inflamed 
cavity ;  or  by  perforating  the  external  wall  of  the  antrum,  in  the 
situation  of  the  canine  fossa.  For  a  time  it  may  be  necessary  for 
the  patient  to  use  a  small  silver  tube  or  some  other  contrivance 
to  prevent  the  wound  healing,  and  to  give  free  vent  to  the  dis- 
charges. 

TUMOTTRS  OF  THE  UPPER  JA'W. 

The  upper  jaw  is  liable  to  be  the  seat  of  tumours  of  various 
kinds.  Of  these  the  commonest  are  the  fibrous,  the  myeloid,  and 
the  medullary.  They  appear  to  originate  in  the  gum,  the  alveoli, 
or  the  antrum.  As  they  grow,  the  bones  become  expanded. 
The  swelling  projects  outwards  on  the  face,  backwards  towards 
the  fauces,  inwards  towards  the  nose,  and  upwards  towards  the 
orbit.  Swallowing  is  impeded,  smell  is  impaired,  vision  is  dis- 
torted, and  the  face  is  terribly  disfigured. 

At  first  it  is  difficult  to  give  any  opinion  as  to  the  precise  nature 
of  the  tumour.  If,  however,  it  grows  slowly,  our  diagnosis  will 
be  more  favourable ;  and  less  favourable,  if  it  grows  quickly.  The 
rapidity  of  growth  is  generally  in  direct  proportion  to  the  malig- 
nancy. Dentigerous  cysts — cysts  containing  undeveloped  teeth 
— are  occasionally  met  with  in  this  situation. 


EPULIS.  255 

Treatment. — The  only  remedy  is  extirpation — removal  of  the 
upper  jaw.  Though  this  is  a  formidable  operation,  yet  the  imme- 
diate result  is  almost  invariably  good.  The  skin  may  be  reflected, 
and  the  tumour  exposed  in  various  ways.  Perhaps  that  which 
leaves  the  least  deformity  is  the  one  recommended  by  Sir  Wm. 
Fergusson.  The  knife  is  carried  through  the  middle  line  of  the 
upper  lip,  and  the  nostril  is  entered.  In  some  cases  this  gives 
sufficient  space.  If,  however,  more  is  wanted,  the  incision  may  be 
continued  round  the  ala,  and  up  the  side  of  the  nose.  If  need  be,  it 
may  be  turned  at  right  angles  along  the  lower  border  of  the  orbit. 

If  the  whole  of  the  upper  maxilla  has  to  be  removed,  the  first 
step,  after  making  the  incision,  is  to  draw  an  upper  incisor  tooth 
on  the  affected  side,  and  divide  the  alveolus  and  the  palate- 
plate  with  a  fine  saw,  or  with  bone-pliers  introduced  into  the 
nostril.  The  internal  angle  should  then  be  similarly  notched 
and  cut  through,  and  subsequently  the  outer  angle  and 
the  zygomatic  process.  The  bone  must  then  be  seized  with 
the  "  lion  forceps"  and  turned  out,  the  soft  tissues  being 
divided  with  a  scalpel,  and  the  wound  closed  with  interrupted 
sutures. 

TUMOURS  OF  THB  IiOlXTER  SA.'W 

are  much  the  same  in  their  characters  as  those  which  are  met 
with  in  the  superior  maxilla.  The  most  common  varieties  are  the 
fibrous  and  the  fibro-cystic.  The  soft  cancer  is  less  often  seen. 
Tumours  are  generally  situated  between  the  angle  and  the  sym- 
physis ;  but  they  may  occur  anywhere,  and  they  have  been  known 
to  occupy  the  whole  extent  of  the  jaw. 

Treatment. — Complete  removal  of  the  tumour,  and  of  the  por- 
tion of  bone  connected  with  it,  is  the  only  remedy.  An  incision 
should  be  made  along  the  lower  border  of  the  bone,  and  the  soft 
tissues  reflected,  so  as  to  expose  the  growth.  The  Key's  saw 
should  then  be  applied  on  each  side  of  the  tumour,  the  jaw 
grooved,  and  the  division  completed  by  the  cutting-pliers ;  or  the 
bone  may  be  divided  from  within  outwards  by  means  of  the 
chain-saw.  When  this  has  been  done,  the  tumour  should  be 
carefully  dissected  from  the  soft  parts  on  its  inner  and  under 
surfaces.  In  performing  this  operation  the  "  lion  forceps"  will 
be  found  of  great  service. 

Maunder  has  shown  that  tumours  which  involve  even  large 
portions  of  the  bone  may  be  removed  through  the  mouth,  with- 
out making  any  incision  through  the  skin  at  all. 

EPUX.IS 

is  the  name  given  to  a  tumour  which  springs  from  the  alveolar 


256  DISEASES  OF  TISSUES  AND  OEGANS. 

processes,  and  from  the  periosteum  covering  them.  It  is  more 
often  seen  in  connection  with  the  inferior  than  with  the  superior 
maxilla.  It  forms  a  smooth,  rounded,  or  lobulated  tumour, 
covered  with  the  mucous  membrane  of  the  gum.  It  is  firm,  or 
semi-elastic  to  the  touch.  As  it  grows,  it  loosens  and  displaces  the 
teeth.  Its  intimate  structure  varies  considerably.  Sometimes 
it  is  a  simple  fibrous  tumour ;  sometimes  it  is  a  round-celled  sar- 
coma ;  sometimes  a  myeloid.  At  first  it  is  benign ;  but  if  it  is 
allowed  to  remain,  it  is  apt  to  ulcerate,  and  exhibit  something  of 
a  malignant  aspect  and  character. 

Treatment. — The  tumour  should  be  removed,  and  the  portion 
of  the  alveolar  process  from  which  it  springs  should  be  taken 
away  with  the  gouge,  the  cutting-pliers,  or  a  fine  saw.  Unless 
this  is  done,  the  growth  is  almost  certain  to  return. 

is  the  name  given  to  an  encysted  tumour  which  is  apt  to  form 
beneath  the  tongue.  It  depends  upon  distension  of  one  of  the 
mucous  follicles,  which  are  numerous  in  this  situation ;  occa- 
sionally it  may  be  due  to  obstruction  of  the  ducts  of  the 
salivary  glands.  The  contained  fluid  is  clear,  viscid,  and 
albuminous.  • 

Treatment. — The  cyst  may  be  simply  punctured  j  or  a  small 
portion  of  the  cyst-wall  may  be  cut  off;  or  a  seton  may  be 
passed  through  it ;  or  it  may  be  laid  open  and  filled  with  lint, 
according  to  its  size,  and  the  circumstances  of  the  case. 

There  is  another  class  of  cases  to  which  the  name  ranula  is 
applied,  but  which  are  in  truth  of  a  difierent,  and  more  formidable 
kind.  Here  the  swelling  is  situated  between  the  tongue  and 
the  jaw,  and  becomes  prominent  in  the  upper  part  of  the  neck. 
These  tumours  contain  a  thick,  gritty,  putty-like  substance  com- 
posed of  crystals  of  cholesterine,  oil-globules,  and  the  debris  of 
epithelial  scales.  In  fact  they  are  of  the  nature  of  sebaceous 
cysts  (see  Fig.  3).  The  best  way  of  treating  these  tumours  is 
to  lay  them  open  from  the  mouth,  scoop  out  the  contents,  and 
fill  the  cavity  with  lint.  If  need  be,  a  counter-opening  should 
be  made  in  the  neck.  To  dissect  out  the  cyst  is  an  unneces- 
sary proceeding,  and  one  which  is  not  altogether  free  from 
danger. 

SAIiZVARV  CiiZiCUIiirS. 

It  sometimes  happens  that  a  deposit  of  earthy  salts  from  the 
saliva — composed  chiefly  of  phosphate  of  lime — takes  place  in 
one  of  the  salivary  glands,  or  in  one  of  the  ducts.     Such  a  con- 


TONGUE-TIE. 


257 


Fig.  114. 


Salivary  calciilus. 


cretion  is  known  as  a  salivary  calculus  (Fig.  114).  These 
concretions  vary  in  size  from  a  pin's  head  to  a  hazel  nut ;  and 
not  unfrequently  they  form 
around  some  foreign  body,  such 
as  a  morsel  of  woody  fibre,  a 
fish-bone,  or  a  bristle. 

Treatment. — If  a  salivary  cal- 
culus can  be  felt  either  by  the 
finger,  or  by  a  probe  passed  along 
the  duct,  an  incision  should  be 
made,  and  it  should  be  removed 
with  a  forceps.  If  it  is  so  small 
as  to  elude  the  grasp  of  the  instrument,  it  will  be  washed  out  at 
the  opening  by  the  discharge  of  saliva. 

TOXJGVE-TZE. 

In  this  affection  the  frcenum  linguce  is  too  short,  or  comes 
further  forward  than  it  should,  and  thus  restrains  the  movements 
of  the  anterior  portion  of  the  organ.  The  infant  cannot  put  out 
its  tongue  or  use  it  in  sucking ;  and,  if  the  defect  is  allowed  to 
continue,  it  seriously  interferes  with  the  distinctness  of  the 
patient's  articulation. 

The  treatment  is  simple  and  effectual.  The  infant's  mouth 
being  held  open,  the  surgeon  takes  the  frcBnum  between  his  Jeft 
forefinger  and  thumb,  puts  it  gently  on  the  stretch,  and  snips  it 
with  a  blunt-pointed  pair 

of  scissors  j  or  the  tongue  ^^'      ^* 

may  be  pressed  upwards, 
and  the  bridle  made  tense, 
by  means  of  the  little 
instrument  which  has  been 
devised  for  the  purpose 
(Fig.  115).  The  incision 
need  not  be  deep.  In 
most  instances  an  eighth 
of  an  inch  will  suffice ;  and  care  should  be  taken  to  direct  the  point 
of  the  scissors  downwards,  so  as  to  avoid  the  ranine  arteries. 
Trifling  as  this  operation  is,  it  has  sometimes  been  followed  by 
severe,  and  even  fatal,  hsemorrhage.  Many  children  are  thought 
by  their  parents  to  be  tongue-tied,  when,  in  truth,  there  is  no 
such  defect.  The  surgeon  should  therefore  be  on  his  guard,  and 
not  undertake  the  operation  without  good  reason. 

VIiCERATIOir  OF  THE  TOXTGVE. 

The  tongue  is  liable  to  be  aftected  with  ulcei-ation  of  various 


Instrument  for  tongue-tie. 


258 


DISEASES  OF  TISSUES  AND  ORaANS. 


kinds — simple,  sypliilUic,  apMhous,  and  cancerous.     Of  the  last 
we  shall  speak  in  the  next  section. 

The  simple  ulcer  may  arise  either  from  internal  or  external 
causes.  When  it  arises  from  internal  causes,  it  is  due  to  derange- 
ment of  the  stoiToach,  and  is  termed  dyspeptic  ;  when  it  is  due  to 
external  causes,  it  will  probably  be  found  to  have  been  produced 
by  a  jagged  tooth  or  an  accumulation  of  tartar.  The  edges  of  a 
simple  ulcer  are  rounded,  the  surface  is  yellow,  the  base  is  soft. 
The  tongue  is  coated,  and  the  breath  oiFensive.  Dr.  T.  Morton,  of 
Kilburn,  has  drawn  attention  to  the  interesting  fact  (which  had 
already  been  observed  on  the  Continent),  that  in  a  large  propor- 
tion of  cases  of  whooping-cough  an  ulcer  is  found  under  the  tongue, 
situated  on  the  frasnum.  Its  cause  and  significance  are  not 
clearly  made  out ;  but  it  is  generally  referred  to  tension  over  the 
teeth  in  coughing. 

Syphilitic  ulceration  occurs  under  three  forms : — (1)  cracks  and 
fissures  along  the  sides  of  the  tongue ;  (2)  superficial,  flat,  oval 

ulcers;  (3)  deep  ulceration,  the 
Fig.  116.  result  of  the  softening,  and  dis- 

charge of  a  gummy  tumour  in 
the  substance  of  the  organ. 

Aphthous  ulcers  are  met 
with  in  infants,  "in  old  persons, 
and  in  the  last  stages  of  some 
wasting  complaints — in  fact, 
wherever  there  is  great  debility. 
They  constitute  what  is  popu- 
larly called  "  the  thrush." 
They  are  due  to  the  develop- 
ment of  a  parasitic  fungus — 
the  oidium  albicans  (Fig.  116), 
which  destroys  the  epithelium 
upon  which  it  grows,  and  then 
the  exposed  mucous  membrane 
ulcerates.  The  disease  first 
appears  on  the  tongue,  or  on  the 
lining  membrane  of  the  mouth, 
as  small  white  flakes,  like 
of  curd,  for  which 
it  is  often  mistaken. 
These  flakes  should  not  be 
picked  off,  for,  if  this  is  done, 
they  are  soon  reproduced.  To 
deal  with  them  successfully  we  must  remove  the  morbid  condition, 
which  favours  their  development. 


Oidium  albicans,  x  300. 


EPITHELIOMA  OF  THE  TONGUE.  iJ59 

Treatment. — In  the  case  of  a  dyspeptic  ulcer  t\ie  primce  vice 
should  be  regulated  by  alteratives,  and  the  general  health  esta- 
blished by  tonics.  Tlie  patient  should  at  the  same  time  confine 
himself  to  a  liquid  and  bland  diet.  If  the  ulcer  is  due  to  local 
irritation,  the  source  of  such  irritation  ought  at  once  to  be 
removed,  and  the  disease  treated  as  in  the  foregoing  case. 

The  surftice  of  the  uk-er  should  be  lightly  touched  with  lunar 
caustic,  and  the  mouth  rinsed  with  stimulating,  astringent,  or 
disinfecting  washes.  The  patient  should  at  the  same  time  be 
desired  to  abstain  from  talking.  In  fact,  everything  should  be 
done  to  keep  the  tongue  at  rest. 

If  the  ulceration  is  syphilitic,  the  same  local  measures  should 
be  adopted,  and  the  patient  should,  in  addition,  be  treated  with 
mercury  or  iodide  of  potassium  (F.  49,  50,  60). 

In  true  aphthous  ulceration  our  aim  must  be  to  destroy  the 
parasitic  fungus  by  lotions  of  sulphite  of  soda  (^j  to  3J  of  water) 
or  carbolic  acid,  while  we  rectify  the  secietious  of  the  mouth  by 
alteratives  and  tonics.  In  infants,  a  well-regulated  manner  of 
nursing  and  strict  attention  to  cleanliness  are  often  all  that  is 
needed  to  effect  a  cure. 

EPITKEXiIO»X.a.   OF    THE  TONOUH 

may  either  commence  as  a  superficial  blister  or  crack,  or  as  a 
lump  in  the  substance  of  the  organ.  If  it  begins  as  a  blister  or 
crack,  it  rapidly  runs  into  ulceration.  A  foul  and  offensive  sore 
is  formed  with  a  sloughy  surface,  ragged  edges,  and  a  hardened 
base.  There  is  acute,  darting  pain.  The  breath  becomes  foetid, 
there  is  profuse  salivation,  and  the  submaxillary,  sublingual, 
and  lymphatic  glands  become  enlarged.  Gradually  the  general 
health  sufiers,  and  the  patient  at  length  dies,  worn  out  by  irri- 
tation and  exhaustion.  When  the  disease  begins  as  a  deep-seated 
lump,  it  draws  the  tissues  down  to  itself,  and  forms  a  hard  mass. 
There  is  little  or  no  ulceration,  but  the  other  features  of  the  case 
are  much  the  same  as  those  of  the  preceding  variety.  It  was 
this  class  of  cases  which  used  to  be  called  scirrhus.  But  it  is 
now  known  that  any  other  form  of  cancer  except  epithelioma  is 
extremely  rare  in  the  tongue. 

Treatment. — Early  and  complete  removal  is  the  only  remedy 
which  holds  out  a  hope.  The  disease  may  be  taken  away  with 
the  knife,  the  ecraseur,  the  galvanic-ecraseur,  or  the  ligature. 
If  the  knife  is  used,  the  hsemorrhage  is  generally  so  profuse  that 
it  is  not  advisable  to  give  chloroform.  But  if  any  of  the  other 
methods  are  employed,  the  patient  can  have  the  comfort  of  an 
anaesthetic.  It  is  but  seldom  that  the  ligature  is  now  used  in 
these  cases.     The  presence  of  a  slough  in  the  patient's  mouth 

s  2 


•260  DISEASES  OF  TISSUES  AND  ORGANS. 

for  a  few  days  after  it  has  been  applied  is  a  great  objection  to 
it.  If  the  base  and  sides  of  the  tongue  are  freed,  or  if  the 
lower  jaw  is  divided,  any  part  of  the  organ  may  be  brought 
within  the  loop  of  the  ecraseur  ;  and  if  this  is  very  slowly 
tightened,  it  gives  all  the  advantages  of  the  ligature  without  its 
disadvantages.  Sometimes  an  incision  is  made  in  the  sub- 
mental region,  and  the  tongue  drawn  through  it.  But  it  is 
better,  if  possible,  to  avoid  any  extensive  wound  in  the  floor  of 
the  mouth.  Nunneley  and  Barwell  have  devised  ingenious 
operations,  wherein  the  wire  of  an  ecraseur  has  been  passed 
through  a  puncture  in  the  floor  of  the  mouth.  (^Lancet, 
April  19,  1879.) 

If  an  operation,  even  of  a  palliative  kind,  is  out  of  the  ques- 
tion, much  may  be  done  by  the  judicious  use  of  conium,  hyos- 
cyaraus,  and  morphia,  to  alleviate  the  patient's  sufferings  (F.  7, 
10,  53).  In  suitable  cases  signal  relief  may  be  afforded  by  the 
operation  recommended  by  C.  H.  Moore — namely,  the  division  of 
the  lingual  nerve,  where  it  lies  against  the  inner  surface  of  the 
lower  jaw,  just  beyond  the  last  molar  tooth. 

Though  cancer  of  the  tongue  is  very  rapidly  fatal — the 
average  duration  of  life  .being  only  fourteen  months — yet  statis- 
tics show  that  the  balance  is  considerably  in  favour  of  cases  that 
have  been  submitted  to  operation.  This  I  have  shown  in  detail 
in  my  treatise  on  the  Diseases  of  the  Tongue. 

GAM-GREITOUS  STOIVIATITZS— CAirCRUnX  ORIS. 

In  ill-fed  children,  living  in  unfavourable  conditions,  we  not 
unfrequently  see  foul  greyish  ulcers  on  the  gums  and  on  the 
inside  of  the  cheeks.     This  is  termed  gangrenous  stomatitis. 

Treatment. — Such  ulcers  may  be  readily  cured  by  touching 
the  diseased  spots  with  lunar  caustic,  and  prescribing  chlorate 
of  potash  in  combination  with  a  tonic ;  while  the  child  is  well 
fed  and  placed  in  favourable  hygienic  conditions. 

But  occasionally  we  meet  with  a  much  more  formidable 
disease  of  the  same  kind,  especially  in  children  who  are  recover- 
ing from  the  eruptive  fevers.  In  cancrum  oris  one  cheek, 
generally  near  the  angle  of  the  mouth,  becomes  swollen,  red, 
and  brawny.  The  whole  thickness  of  the  cheek  is  affected. 
The  internal  surface  is  as  painful  as  the  external ;  and  the  little 
patient  can  scarcely  open  his  mouth.  Gradually  the  redness 
passes  into  lividity.  A  large  slough  forms,  and,  when  it  sepa- 
rates, the  teeth  and  the  interior  of  the  mouth  are  exposed  to 
view. 

Treatment. — Everything  must  be  done  to  support  the 
patient's  strength  by  milk,  beef-tea,  wine,  and  stimulant  medi- 


CLEFT  PALATE.  261 

cines.  A  suitable  mouth-wash — containing  tincture  of  myrrh 
or  Condy's  fluid,  or  some  other  detergent — should  be  frequently 
used.  The  cheek  must  be  covered  by  a  poultice  or  a  fomenta- 
tion till  the  slough  separates,  and  then  the  raw  surfaces  dressed 
with  a  stimulating  lotion  (F.  13,  22,  25).  If  the  gangrenous  in- 
flammation threatens  to  spread,  the  edges  must  be  thoroughly 
touched  with  the  strong  nitric  acid.  But,  under  any  circum- 
stances, cancrum  oris  is  a  very  fatal  disease. 

CIiEFT  PAXiiVTE 

signifies  a  congenital  fissure  in  the  palate,  the  result  of  defective 
development.  The  cleft  varies  greatly,  both  in  extent  and  width, 
in  different  cases.  It  may  be  confined  to  the  tip  of  the  uvula, 
or  it  may  sweep  through  the  whole  arch  of  the  soft  and  hard 
palate,  and  be  associated  with  hare-lip.  Sometimes  it  is  quite 
narrow — a  mere  slit ;  sometimes  it  is  nearly  an  inch  in  breadth. 
In  a  severe  case  food  regurgitates  by  the  nose,  causing  great 
difficulty  in  rearing  the  infant,  and  great  inconvenience  in  after 
life.     The  patient's  speech,  too,  will  be  nasal  and  indistinct. 

Treatment. — If  the  soft  tissues  are  abundant,  and  the  patient's 
health  good,  an  operation  may  be  undertaken  with  the  view  of 
remedying  the  defect.  If  the  soft  palate  alone  is  cleft,  it  may  be 
united  without  any  great  difficulty.  If  the  hard  palate  is  only 
slightly  fissured,  the  surgeon  may  be  able  to  close  the  soft  tissues 
over  it.  But  if  there  is  a  large  gap,  the  patient  must  be  con- 
tented to  wear  an  artificial  palate.  When  the  soft  palate  has 
been  united,  a  plate  will  more  easily  be  worn  in  the  aperture 
which  remains  in  the  hard  palate. 

The  operation  of  velosyyithesis  or  stapliyloraphy  consists  in 
paring  the  edges  of  the  cleft,  bringing  the  soft  tissues  together, 
and  keeping  them  in  that  position  until  they  have  united.  In 
order  to  allow  the  parts  to  come  together  more  easily,  and  to 
prevent  traction  upon  the  stitches,  Sir  Wm.  Fergusson  divided 
the  levator  palati  and  the  palato-pharyngeus  muscles  on  both 
sides  at  the  outset  of  the  operation.  Others  prefer  making  an 
incision  through  the  soft  parts  on  each  side  of,  and  parallel  to, 
the  line  of  union.  The  sutures  used  should  be  of  fine  silk, 
fishing-gut,  horse-hair,  or  silver  wire  ;  and  if  they  cause  no  irri- 
tation, they  should  be  allowed  to  remain  for  a  week. 

The  earlier  this  operation  is  undertaken  the  better  chance  will 
the  patient  have  of  speaking  clearly  and  distinctly.  Formerly  it 
was  usual  to  defer  it  until  the  child  was  of  sufficient  age  to  exer- 
cise some  degree  of  self-control.  For  this  reason  it  was  seldom 
undertaken  before  the  age  of  puberty.  Lately,  however,  opera- 
tions have  been  performed   at  a  much  earlier  age,  both  with 


262  DISEASES  OF  TISSUES  AND   OEQANS. 

and  without  the  aid  of  chloroform.  In  these  proceedings,  Mr. 
1'homas  Smith's  gag  will  be  found  of  great  service.  It  is  a  sort 
of  double  bit,  which  is  introduced  into  the  patient's  mouth  and 
secured  by  a  strap,  which  passes  round  the  head.  The  two 
portions  are  then  separated  by  a  screw,  and  thus  the  mouth  is 
opened  to  the  full  extent.  At  the  same  time  the  tongue  is  de- 
pressed by  a  tongue-plate,  and  this  gives  the  operator  a  full 
view  of  the  fauces. 

Some  surgeons  detach  the  mucosa  from  the  hard  palate,  in  a 
direction  from  the  alveolar  ridge  towards  the  margins  of  the 
fissure,  so  as  to  relax  the  tissues  and  allow  them  to  come 
together ;  and  some  have  stripped  off  the  periosteum  in  a  similar 
manner  in  the  hope  that  it  might  cause  the  fissure  to  be  closed 
by  new  bone. 

ACUTE  INFIiAniniATION-  OF  THE   TOlTSIXi 

(Tonsillitis,  cynancTie  tonsillaris,  quinsy)  is  attended  by  urgent 
symptoms,  and  a  high  degree  of  fever.  There  is  rapid  swelling, 
with  pain  which  extends  over  the  side  of  the  face  and  neck. 
Usually  one  tonsil  is  solely  or  chiefly  affected.  If  both  are  in- 
volved, swallowing  becomes  difficult,  speech  is  thick  and  indistinct, 
and  breathing  is  somewhat  impeded. 

The  treatment  should  be  active,  and  a  brisk  purgative  should 
be  given,  to  be  followed  by  a  saline  mixture.  Locally,  the 
throat  should  be  well  steanned ;  and  leeches,  mustard  poultices, 
or  fomentations  applied  externally.  In  some  parts  of  the 
country  there  is  a  popular  notion  that  a  poultice  made  of  quinces 
is  a  cure  for  the  disease.  Hence  they  call  that  fruit  the  "  quinsy- 
apple."  No  doubt  the  belief  has  arisen  from  the  similarity  of 
the  names,  though  the  etymological  derivation  of  the  words  is 
quite  different ;  and  the  efficacy  of  the  remedy  does  not  consist 
in  the  particular  fruit,  but  in  the  warmth  and  moisture  of  the 
application.  Much  relief  may  sometimes  be  given  by  scarifying 
the  part  so  as  to  facilitate  the  pointing  and  escape  of  pus. 
Tanner  remarks  that  those  cases  generally  do  best  which  are  not 
opened  with  the  knife.  If  there  is  reason  to  think  that  matter 
has  formed,  and  the  symptoms  are  so  urgent  that  the  surgeon 
thinks  it  necessary  to  let  it  out  at  once,  the  tonsil  should  be 
punctured — the  point  of  the  knife  being  directed  towards  the 
middle  line  of  the  body. 

CHROXrXC  ESriiARGEMEM'T    OF    THE   TOIUSIIi 

is  usually  tlie  result  of  repeated  subacute  attacks  of  tonsillitis,  but 
sometimes  it  is  brought  about  by  a  slow  and  chronic  inflammation. 
The  latter  is  often  the  case  in  young  persons  of  a  scrofulous  habit. 


STRICTURE  OF  THE  (ESOPHAGUS.  263 

The  tonsils  become  enlarged  and  hardened.  There  is  slight 
difficulty  in  swallowing,  some  indistinctness  of  articulation,  and 
perhaps  deafness.  The  patient,  moreover,  is  constantly  liable  to 
acute  attacks  of  sore  throat  supervening  on  the  chronic  state. 

The  treatment  consists  in  improving  the  general  health,  more 
particularly  if  the  patient  is  young  and  strumous.  Locally,  the 
disease  should  be  treated  with  gargles  of  alum  or  sulpliate  of 
zinc,  or  painted  with  a  solution  of  nitrate  of  silver,  or  a  mixture 
of  tincture  of  steel  and  glycerine.  If  these  means  are  fairly  tried 
and  found  ineffectual,  a  portion  of  the  tonsil  must  be  removed. 

EXCISIOM*  OF   THE  TOirSIZi. 

Though  several  ingenious  instruments  under  the  name  of 
tonsil-guillotines  have  been  devised,  I  believe  the  method  so  tersely 
described  by  Celsus,  hamulo  excipere  et  scalpello  excidere,  has 
never  been  superseded, .  and  that  the  best  way  of  performing 
this  operation  is  with  a  long  hooked  forceps  and  a  blunt- 
pointed  bistoury.  The  blade  of  the  knife  should  be  wrapped 
round  with  a  strip  of  plaster  or  lint,  so  as  to  leave  only  about  an 
inch  at  the  end  exposed.  The  tonsil  is  seized  with  the  forceps, 
and  drawn  gently  forwards  and  inwards  towards  the  middle  line. 
Tlie  bistoury  is  then  introduced  under  it,  and  a  slice  is  taken  off, 
cutting  from  below  upwards.  In  excising  the  right  tonsil,  the 
surgeon  may  find  it  convenient  to  stand  behind  his  patient.  A 
pair  of  curved,  blunt-pointed  scissors,  or  the  wire  ecraseur,  may 
sometimes  be  used  with  advantage  instead  of  the  knife.  The 
bleeding  is  generally  stopped  without  difficulty  by  washing  out 
the  mouth  with  cold  water.  The  cicatrization  and  contraction, 
which  follow  the  removal  of  even  a  small  slice  of  the  tonsil, 
generally  produce  the  desired  effect.  If  need  be,  the  operation 
may  be  perfurmed  upon  both  tonsils  at  the  same  time. 

STRICTURE  OF  THE  CESOPHAGVS 

may  be  either  spasmodic  and  temporary,  or  organic  and  perma- 
nent. 

Spasmodic  stricture  is  generally  met  with  in  nervous  and 
hysterical  young  women. 

The  treatment  should  consist  in  re-assuring  the  patient  and 
strengthening  the  constitution  by  those  general  remedies  which 
have  been  described  in  speaking  of  hysteria  (see  p.  93).  Any 
local  measures  that  may  be  adopted  should  be  of  the  mildest 
kind,  such  as  may  satisfy  the  patient,  without  directing  too  much 
attention  to  the  part. 

Organic  stricture  may  be  either  simple  or  malignant. 

Simple  stricture  may  be  the  result  of  spontaneous  infiamma- 


264  DISEASES  OF  TISSUES  AND  ORGANS. 

tion,  or  of  syphilitic  ulceration,  or  of  injury  sustained  by  swallow- 
ing strong  acids,  alkalies,  boiling  fluids,  &c.  Such  strictures 
have  a  fibrous  texture,  and  are  prone,  in  the  course  of  time,  to 
assume  the  characters  of  epithelioma. 

Malignant  stricture  is  caused  by  the  presence  of  a  cancerous 
tumour  in  the  substance  of  the  oesophagus,  or  in  its  immediate 
neighbourhood. 

Symptoms. — There  is  diflSculty  in  swallowing  solid  food.  This 
difficulty  is  permanent,  goes  on  gradually  increasing,  and  is 
evidently  not  dependent  upon  pressure  upon  the  oesophagus  from 
without.  There  is  pain  in  the  neck  and  shoulders,  and  retching, 
with  regurgitation  of  food. 

The  most  common  seat  of  stricture  is  at  the  junction  of  the 
pharynx  and  oesophagus,  opposite  the  cricoid  cartilage.  Various 
morbid  conditions  external  to  the  oesophagus,  such  as  aneurysms 
and  intra-thoracic  tumours,  may  need  to  be  carefully  distinguished 
from  stricture. 

The  treatment  of  organic  stricture  consists  in  passing  oesophagus- 
bougies,  so  as  to  dilate  the  passage  and  keep  it  open.  In  spite 
of  this,  the  disease  will  probably  get  gradually  worse,  until  at 
length  it  will  become  impossible  to  pass  even  the  smallest  gum 
catheter.  The  patient  may  then  be  kept  alive  for  a  few  days  or 
weeks  by  nutritive  enemata,  or  by  the  performance  of  gastrotomy  j 
but  death  by  starvation  is  inevitable. 

In  stricture  of  the  oesophagus,  in  wounds  of  the  throat,  in 
cancer  of  the  pharynx  and  tongue,  it  is  often  necessary  to  feed  the 
patient  by  means  of  the  stomach-pump. 

Use  of  the  stomach-pump. — The  patient  should  be  seated  in  a 
chair  with  his  head  thrown  back,  and  his  mouth  open.  The  tube 
of  the  stomach-pump  should  be  oiled,  and  slightly  curved  at  the 
end-  It  should  then  be  introduced  into  the  mouth,  and  directed 
down  the  pharynx  ;  at  the  same  time  the  patient's  head  should  be 
gently  bent  forwards,  so  as  to  throw  the  cervical  and  dorsal 
vertebrae  into  one  equal  curve.  The  tube  should  then  be  pushed 
on  steadily  into  the  stomach.  The  chief  dangers  are  lest  the 
point  should  pass  into  the  larynx,  or  the  coats  of  the  stomach  be 
injured.  If  the  patient  is  insensible  or  lunatic,  the  wooden 
gag  must  be  placed  between  his  teeth  to  keep  the  mouth  open. 

If  our  object  in  using  the  pump  is  to  remove  noxious  matters 
from  the  stomach,  warm  water  should  be  injected  each  time  that 
suction  is  made,  care  being  taken  to  inject  always  rather  more 
than  is  withdrawn.  It  is  in  cases  of  alcoholic  or  narcotic  poison- 
ing that  the  pump  is  generally  used  to  empty  the  stomach. 


265 


FOREZGir  BODIES  ZK  THE  PHABVZTX 

may  destroy  life  in  two  ways — either  by  pressing  on  the  glottis, 
and  thus  causing  spasm  and  suffocation  ;  or  by  leading  to  ulcera- 
tion and  perforation  of  the  walls  of  the  pharynx. 

Treatment. — The  sutgeon  should  explore  the  fauces  and 
pharynx  with  his  finger.  If  anything  can  be  felt,  it  should  be 
withdrawn  with  the  nail,  or  seized  with  a  forceps.  If  nothing 
can  be  felt,  the  long,  curved  scissor-forceps  should  be  introduced, 
in  the  hope  of  finding  the  foreign  body  in  tlie  lower  part  of  the 
pharynx ;  or  an  emetic  may  be  given  with  the  view  of  dislodging 
it  upwards  ;  or  it  may  be  pushed  on  into  the  stomach  by  cautiously 
passing  a  bougie.  But  if  it  can  be  avoided,  this  last  plan  ought 
not  to  be  adopted  in  the  case  of  hard,  angular  bodies,  such  as 
bones,  or  the  plates  of  artificial  teeth. 

FOREIGir  BODIES  IN"  THE  X^ARVSTX,  TRACHEA, 
AND  BROirCHI. 

Foreign  bodies — such  as  beads,  pins,  coins,  morsels  of  food,  &c. 
— are  sometimes  drawn  from  the  mouth  into  the  larynx  by  a 
sudden  act  of  inspiration.  They  may  lodge  in  the  rima  glottidis, 
in  the  ventricles  of  the  larynx,  in  the  trachea,  or  in  the  bronchi, 
more  particularly  in  the  right  bronchus. 

When  the  rima  glottidis  is  obstructed,  the  patient  is  seized  with 
a  sudden  difficulty  in  breathing,  his  face  becomes  livid  and 
swollen,  and  he  speedily  falls  down  insensible  and  moribund. 

When  the  foreign  body  is  situated  either  in  the  folds  of  the 
larynx,  or  in  the  trachea,  or  in  the  bronchi,  the  leading  symptom 
is  violent,  suffocative,  spasmodic  cough.  When  in  the  bronchi, 
this  cough  comes  on  at  intervals;  when  in  the  larynx,  it  is  almost 
constant.  By  the  laryngoscope,  or  by  auscultation  and  percussion, 
the  position  of  the  foreign  body  may  sometimes  be  ascertained  with 
tolerable  accuracy.  After  it  has  been  lodged  for  some  time,  it  will 
probably  give  rise  to  secondary  symptoms  of  an  inflammatory  kind. 

Treatment. — When  the  rima  glottidis  is  obstructed,  the  treat- 
ment must  be  immediate.  The  trachea  should  be  opened  without 
delay,  and  a  probe  passed  upwards  to  dislodge  the  foreign  body ; 
and,  if  need  be,  artificial  respiration  must  be  practised. 

When  the  foreign  body  is  impacted  in  the  ventricles  of  the 
larynx,  it  may  perhaps  be  removed,  by  the  help  of  the  laryngo- 
scope and  a  suitable  forceps.  If  it  has  made  its  way  into  the 
trachea  or  bronchi,  tracheotomy  must  be  performed,  and  an 
attempt  made  to  remove  it  by  inverting  the  patient,  or  by  intro- 
ducing a  long  scissor-forceps. 


266 


DISEASES   OF  TISSUES  AND  OEGANS. 


Fig.  117. 


But  it  is  highly  probable  that,  after  all,  we  shall  be  unable  to 
dislodge  or  remove  the  foreign  body.  In  such  a  case,  it  will  either 
become  encysted  and  give  no  further  trouble,  or  the  patient  will 
speedily  die,  worn  out  by  the  irritation  and  subsequent  inflam- 
mation which  it  occasions. 

IVRV-XTECK  (TORTICOIi]LZS) 

is  a  disease  which  consists  in  a  permanently  contracted  state  of 
the  sterno-mastoid  muscle  of  one  side.  Sometimes  the  trapezius 
is  involved  as  well ;  and  in  rare  cases  both  sides  are  aifected, 
though  in  different  degrees.  The  origin  of  the  disease  seems  to 
be  a  faulty  condition  of  the  spinal  accessory  nerve.  This  appears 
to  be  sometimes  congenital;  but  more  often  it  is  induced  in 
early  life  by  the  irritation  of  a  common  cold  and  swelled  face,  or 
of  enlarged  cervical  glands.  The  head  is  drawn  downwards  and 
sideways,  while  the  face  is  turned  towards  the  opposite  side. 

Treatment. — A  bandage,  or  a  mechanical  appliance,  should  be 
worn,  so  as  to  try  and  draw  the  head  into  its  proper  position.  If 
this  produces  no  effect,  the  sternal  and  clavicular  attachments  of 
the  sterno-mastoid  muscle  must  be  subcutaneously  divided,  and 
the  treatment  by  bandages  and  mechani- 
cal means  continued.  The  subcutaneous 
division  of  the  attachment  of  the  sterno- 
mastoid  muscle  is  a  delicate  operation 
on  account  of  the  important  parts  which 
lie  behind  it.  It  must,  therefore,  be 
undertaken  with  caution. 

In  some  instances  a  portion  of  the 
spinal  accessory  nerve  has  been  excised 
with  a  good  result. 

Bandage  for    wry-necTc. — A    broad 
rib-bandage  is  first  applied  to  the  chest, 
immediately    below    the   armpits.      An 
ordinary  roller  is  then  fixed   by  a  few 
circular     horizontal    turns    round    the 
head,    and    secured    by   pins    over  the 
temple  on  the  side  towards  which  the 
surgeon  desires  to  draw  the  head.     The 
roller  is  then  carried   downwards  and 
backwards,  and  passed  under  the  axilla 
of  the  same  side,  and  fastened  in  front 
to  the  rib-bandage,    A  cushion  or  pad  should  be  placed  in  the  arm- 
pit, so  as  to  prevent  the  roller  from  irritating  the  skin  (Fig.  117). 
Dr.   Little   recommends  that,  in  young  subjects,   a  strip  of 
adhesive  plaster  should  be  pasued  round  the  forehead  and  another 


Bandage  for  wry-neck. 


WOUNDS   OF  THE  THROAT. 


267 


round  the  waist ;  and  that  then  a  ribbon  should  be  attached  to 
the  plaster  immediately  above  the  ear  on  the  unaffected  side, 
carried  diagonally  across  the  chest  to  the  opposite  side  of  the 
waistbantl,  and  there  fastened. 

Such  bandages  as  these  are  useful  not  only  in  cases  of  spas- 
modic contraction  of  the  sterno-mastoid  muscle,  but  also  in  certain 
operations,  and  in  burns  and  wounds  about  the  neck. 

-WOVITDS   OF   THB  THROAT 

are  generally  inflicted  with  a  murderous  or  suicidal  intent.  In 
the  latter  case  the  prognosis  is  particularly  unfavourable,  on 
account  of  the  mental  condition  of  the  patient.  Any  part  of  the 
throat  may  be  wounded,  and  the  cut  may  be  either  superficial  or 
deep.  If  the  larynx  or  trachea  alone  is  wounded,  recovery  will 
probably  take  place,  but  if  the  large  vessels  have  been  divided, 
death  will  be  speedy  and  inevitable. 

Treatment. — Our    first    care  is  to  arrest  haemorrhage.     The 
wound  should  be  cleaned,  coagula  removed,  and  the  bleeding 
stopped  by  ligatures,  pres- 
sure,   or    styptics.       Our  ^^'        * 
next  object    is    to  facili- 
tate breathing  by  keeping 
the  trachea  in  position — 
supposing     it     to     have 
been  wholly  or  partially 
divided.        The     patient 
should    be    laid    in    bed 
with  his    head  bent   for- 
wards, so  as  to  bring  the 
edges  of  the  wound  into 
apposition. 

In  such  injuries  we 
endeavour,  as  far  as  pos- 
sible, to  adjust  the  posi- 
tion of  the  patient  by 
means  of  pillows;  but 
if  he  is  refractory,  and 
milder  measures  fail,  we 
have  recourse  to  the  fol- 
lowing contrivance  : — A 
bandage  is    first   applied 

round  the  chest,  immediately  below  the  armpits.  An  ordinary 
double-headed  roller  is  then  passed  under  the  chin,  carried  up  on 
each  side  of  the  head,  crossed  upon  the  vertex,  brought  down  equally 
on  both  sides,  and  firrnlv  fastened  in  front  to  the  broad  bandage 


Baudaare  for  wounds  of  uuck. 


268  DISEASES  OF    TISSUES  AND  OEGANS. 

which  encircles  the  chest.  A  few  horizontal  turns  may  then  be 
made  round  the  forehead,  so  as  to  fix  the  bandage  (Fig.  118). 
Sometimes,  before  the  roller  is  applied,  a  nightcap  is  placed  on  the 
patient's  head.  This  is  not  a  necessary  part  of  the  bandage,  but 
it  serves  to  make  it  more  secure.  By  these  means  the  head  can 
be  bent  upon  the  chest,  and  retained  at  any  angle  that  may  be 
thought  proper.  No  plasters  or  sutures  should  be  applied  to  the 
incision,  except  when  the  trachea  is  completely  divided,  and  it  is 
necessary  to  preserve  its  continuity.  The  wound  should  be 
lightly  covered  with  water-dressing. 

If  the  patient  is  unruly,  and  tries  to  tear  open  the  wound,  he 
must  be  restrained  by  a  strait-waistcoat. 

When  the  lary^nx  or  trachea  have  been  freely  opened,  or  when 
the  oesophagus  has  been  wounded,  it  may  be  necessary  to  feed  the 
patient  by  means  of  the  stomach-pump.  The  tube  should  be 
introduced  through  the  mouth  two  or  three  times  a  day. 

Every  precaution  should  be  taken  to  prevent  inflammation  of 
the  larynx  or  lungs.  The  patient's  throat  should  be  lightly 
covered  with  flannel,  and  he  should  breathe  a  warm,  moist  atmo- 
sphere of  about  80°  Fahr,  If  there  are  symptoms  of  bronchitis  or 
pneumonia,  sinapisms  or  turpentine  stupes  should  be  applied  to 
the  chost,  while  stimulants  and  expectorants  are  administered. 

In  every  case  of  "  cut-throat"  the  surgeon  should  be  careful  to 
note  down  without  delay  the  exact  direction,  situation,  and  extent 
of  the  wound,  together  with  all  the  other  particulars,  as  he 
may  have  to  give  evidence  in  a  court  of  law. 

BROirCHOCEXiE 

(or  goitre)  is  the  name  given  to  an  hypertrophy  of  the  thyroid 
gland.  Such  hypertrophy  is  simple  in  its  origin,  but  it  may  be- 
come either  cystic  or  malignant.  The  disease  is  endemic  in  some 
parts  of  Great  Britain — in  Derbyshire,  for  example.  But  it  is  in 
the  Alpine  valleys  that  it  is  most  frequently  seen,  and  that  it 
attains  its  greatest  size.  The  allusion  which  Juvenal  makes  to 
the  tumidum guitur  is  well-known  (xiii.  163).  In  Switzerland  and 
Italy  it  is  often  associated  with  the  degraded  mental  and  physical 
condition  to  which  the  term  cretinism  is  applied.  In  this 
country  it  is  only  seen  in  its  milder  forms. 

Bronchocele  has  been  refe^ed  to  a  great  variety  of  causes. 
Some  have  thought  that  it  is  due  to  the  peculiar  waters  of  the 
district ;  but  it  is  much  more  probable  that  the  damp  and  stagnant 
air  of  a  valley,  the  want  of  sunlight,  marriages  of  consanguinity, 
and  the  conditions  of  hardship  and  privation  under  which  the 
sufferers  too  often  live,  combine  to  produce  the  more  aggravated 
c<i£t;s. 


BRONCHOCELE.  269 

It  is  more  common  in  women  than  in  men,  and  is  particularly 
apt  to  show  itself  about  the  age  of  puberty. 

The  gland  enlarges  gradually  without  pain.  At  first  it  occa- 
sions only  a  slight  deformity  ;  but  as  it  increases,  it  gives  rise  to 
giddiness,  headache,  and  difficulty  of  breathing  and  swallowing. 
If  a  part  only  of  the  gland  is  enlarged,  it  may  be  mistaken  for 
aneurysm  of  the  carotid.  In  making  the  diagnosis,  it  is  of  great 
importance  to  remember  that  a  bronchocele  rises  and  falls  with  the 
trachea  in  the  act  of  deglutition. 

As  it  grows,  cysts  may  become  developed  in  the  tumour,  and 
even  attain  a  considerable  size ;  or  it  may  undergo  a  cancerous 
degeneration. 

Thero  is  a  remarkable  prominence  of  the  eyeballs — known  as 
proptosis  or  exophthalmos — which  is  frequently  associated  with 
goitre.  This  condition  seems  to  depend  upon  hypertrophy  of  the 
adipose  tissue  of  the  orbit,  and  to  arise  from  a  want  of  tone  and 
strength  in  the  vascular  system,  for  it  is  invariably  ushered  in  and 
accompanied  by  anaemia.  Sometimes  the  protrusion  becomes  so 
great  that  the  lids  are  unable  to  cover  the  globes,  and  the  cornea 
suffers  severely  from  exposure  to  wind,  dust,  &c.  I  have  seen  a 
young  woman  with  a  well-marked  goitre,  who  had  lost  both  her 
eyes  by  suppurative  inflammation  produced  in  this  way. 

Treatment. — In  the  case  of  a  simple  bronchocele  of  moderate 
size  and  recent  growth,  it  is  generally  sufficient  to  place  the 
patient  in  a  pure  aii- — if  possible,  at  the  seaside — to  regulate  the 
health,  to  apply  the  tincture  of  iodine  over  the  tumour,  and  to 
give  iodide  or  bromide  of  potassium  internally,  with  iron,  quinine, 
or  other  tonics  (F.  57, 60,  65,  66).  A  mixture  in  equal  parts  of 
the  ung.  hyd.  and  the  ung.  iodi.  may,  as  a  change,  be  substituted 
for  the  tinct.  iodi. ;  or  the  ung.  hyd.  biniodidi  may  be  occa- 
sionally and  cautiously  applied.  Dr.  Elmslie,  who  saw  a  great 
deal  of  this  disease  in  Kashmir,  recommends  that  the  biniodideof 
mercury  should  be  employed  at  the  same  time  both  internally  and 
externally  (F.  81).  In  all  cases  associated  with  anaemia  iron 
should  certainly  form  part  of  the  treatment  (F.  45,  47,  48). 

If  these  means  fail,  and  the  tumour  is  growing  so  as  to  become 
dangerous  to  life,  setons  may  be  passed  through  it  in  various 
directions ;  or  the  arteries  leading  to  it  may  be  tied ;  or  the  skin 
may  be  reflected,  and  portions  of  the  gland  removed  with  the 
knife,  the  ecraseur,  or  the  ligature.  But  these  operations  are 
attended  by  much  risk,  in  consequence  of  the  haemorrhage  which 
may  ensue ;  and  the  benefit  that  is  likely  to  arise  from  them  is  very 
uncertain.  Belief  may  sometimes  be  afforded,  or  dangerous 
pressure  removed,  by  division  of  the  sterno-mastoid  muscles.  If 
cysts  have  formed,  they  may  be  punctured,  or  tapped  and  injected 


270  DISEASES   OF   TISSUES  AND   OEGANS. 

with  a  solution  of  iodine,  or  setons  may  be  passed  through  them. 
But,  on  the  whole,  the  treatment  of  bronchocele  by  operative 
means  is  very  unsatisfactory. 

PARACESTTESIS  THORACIS. 

The  surgeon  is  sometimes  required  to  make  an  opening  into  the 
chest  in  cases  of  pleurisy  and  empyema.  The  operation  is  called 
paracentesis  thoracis,  or  tapping  the  chest. 

The  conditions  which  demand  this  operation  are  all  attended 
by  somewhat  similar  symptoms.  The  chest  is  dull  on  percussion, 
and  distended.  The  ribs  are  unusually  far  apart,  and  appear  to 
be  depressed  in  consequence  of  the  bulging  of  their  interspaces. 
The  patient  has  difficulty  in  breathing,  and  is  unable  to  lie  on  the 
affected  side. 

Sometimes  the  fluid  which  is  drawn  off  is  serous — pleuritic 
effusion  {hydrothorax) ;  sometimes  it  is  purulent  {empyema). 

As  a  general  rule,  the  space  between  the  fifth  and  sixth,  or  the 
sixth  and  seventh  ribs,  and  a  little  in  front  of  the  angles,  is  the 
most  eligible  spot  for  operation.  An  incision  about  an  inch  long 
should  be  made  through  the  skin  over  the  lower  rib  of  the  inter- 
space chosen.  The  skin  should  then  be  drawn  up*  and  a  trochar 
and  canula  thrust  sharply  into  the  chest  at  the  lower  part  of  the 
interspace.  The  operation  is  performed  in  this  way  to  avoid  the 
vessels  which  lie  at  the  upper  part  of  the  interspace,  under  cover 
of  the  superjacent  rib.  Various  instruments  have  been  de- 
vised for  drawing  off  the  fluid  without  permitting  the  entrance 
of  air.  As  soon  as  the  canula  has  been  withdrawn,  the  skin 
returns  to  its  original  situation  and  closes  the  opening.  The 
superficial  ineision  should  be  covered  with  a  piece  of  plaster.  The 
aspirator  promises  to  be  very  useful  in  these  cases  (see  Fig.  1). 

If  the  fluid  is  serous,  the  greatest  care  should  be  taken  to  avoid 
the  entrance  of  air  ;  but  if  it  is  purulent,  a  free  opening  and  the 
introduction  of  a  drainage-tube,  is  probably  the  best  mode  of 
treatment. 

If  the  pleural  cavity  is  washed  out  with  warm  water,  or  with 
a  medicated  fluid,  the  surgeon  should  remember  that  this  pro- 
ceeding, simple  as  it  sounds,  has  occasionally  induced  fatal  syn- 
cope. He  should,  therefore,  give  a  stimulant  before  he  begins, 
and  should  proceed  in  the  gentlest  possible  manner. 

BYPERTROPHV   OF   THZ!  BREAST 

is  occasionally  met  with  in  pregnant  women.  In  girls  it  some- 
times occurs  about  the  age  of  puberty.  One  breast  may  be 
alfected,  or  both.  The  whole  gland  slowly  enlarges.  There  is 
no  pain,  unless  it  be  of  an  hysterical  or  neuralgic  kind.      The 


HYPERTROPHY  OF  THE  BREAST. 


271 


tumour  feels  firm,  and  is  free  from  tenderness.  It  may  attain 
an  enormous  size  and  weight,  so  as  to  be  quite  a  burden.  If  it  is 
not  associated  with  pregnancy,  there  is  generally  some  irregu- 
larity of  the  menstrual  discharge. 

The  treatment  consists  in  improving  and  regulating  the  general 
health  by  ferruginous  tonics  and  a  change  of  air,  in  giving  saline 
aperients,  in  rubbing  the  breast  gently  with  stimulating  oint- 
ments and  liniments,  and  in  supporting  it  with  a  bandage.  As  a 
last  resource  in  extreme  cases  excision  has  been  practised. 
William  Hay  has  related  the  case  of  a  girl,  aged  fourteen,  in 
whom  both  breasts  were  enormously  enlarged.  He  amputated 
the  left  breast,  and  it  weighed  eleven  pounds  and  four  ounces. 

Bandages  for  the  breast. — In  some  cases  the  breast  may  be 
suflBciently  supported  by  a  large  handkerchief,  folded  in  the  form 
of  a  broad  cravat,  and  passed  under  the  affected  organ — the 
ends  being  brought  round,  one  across  the  back  and  the  other 
across  the  chest,  and  tied  on  the  opposite  shoulder. 

A  more  efficient  bandage,  both  for  supporting  and  also  com- 
pressing the  breast,  may  be  made  by  taking  a  piece  of  calico, 
about  a  foot  wide  and  a  yard  and  a  half  long,  and  tearing  it 
down  the  middle  from  each  end  to  within  six  or  eight  inches  of 
the  centre.  The  central  portion  is  applied  over  the  affected 
organ,  and  the  two  lower  tails  are  carried  horizontally  round  the 
body,  one  in  front  and  the  other  behind,  and  tied  at  the  opposite 
side.  The  two  upper  tails  are  then  tied  round  the  neck,  or  they 
may  be  conducted,  one  under 
the  axilla  of  the  affected  side 
and  the  other  over  the  op- 
posite shoulder,  and  fastened 
behind. 

Again,  one  or  both  breasts 
may  be  bandaged  by  means 
of  an  ordinary  roller.  In  this 
case  the  roller  ought  to  be 
of  full  length,  and  at  least  as 
wide  as  a  "  leg-bandage." 

When  one  breast  only  has 
to  be  bandaged,  tlie  surgeon 
begins  by  taking  a  turn  round 
the  body  so  as  to  fix  the  end 
of  the  roller.  He  then  con- 
ducts it  obliquely  from  below 
upwards  across  the  lower  margin  of  the  affected  breast,  over 
the  opposite  shoulder,  and  so  round  to  the  point  from  which  he 
started.     He  then  makes  a  circular  turn  round  the  body,  to  fix 


Bandage  for  one  breast. 


272 


DISEASES  OF  TISSUES  AND  OUaANS. 


the  oblique  one  and  prevent  it  from  slipping  ]  after  which  he 
carries  the  bandage  for  the  second  time  obliquely  across  the 
chest,  rising  a  little  higher  than  before,  and  covering  a  little 
more  of  the  breast  than  he  did  with  the  first  fold.  He  then 
makes  another  circular  turn  round  the  body  to  fix  the  second 
oblique  fold,  and  then  a  third  oblique  one,  and  so  on  until  a 
sufficient  number  of  turns  have  been  applied  to  support  or  com- 
press the  breast,  according  to  the  purpose  for  which  the  bandage 
is  employed  (Fig.  119).     Or  the  oblique  turns  may  be  placed 

immediately  over  one   an- 
£  ig.  12 U.  other,  and  secured  by  pins, 

or  by  stitches;  omitting 
all  the  circular  turns  round 
the  body  except  the  first, 
which  is  necessary  to  secure 
the  commencement. 

When  both  breasts  have 
to  be  bandaged  the  surgeon 
fixes  the  roller,  and  makes 
his  first  oblique  turn, 
exactly  as  ii»  the  foregoing 
case.  But  his  second 
oblique  turn  he  makes 
from  above  downwards  over 
the  other  breast,  and  thus 
he  goes  on,  carrying  the 
oblique  turns  first  over 
one  breast,  and  then  over  the  other,  until  he  has  afforded  the 
required  amount  of  support  to  both  (Fig.  120). 

ILCTJTJi  IIO'FIi.A.MMATIOir  OF  THE   BREAST. 

The  breast  is  liable  to  be  acutely  inflamed  from  blows  and  other 
external  injuries,  but  it  still  more  often  becomes  affected  spon- 
taneously during  lactation.  The  inflammation  may  take  place 
either  in  the  subcutaneous  cellular  tissue,  or  in  the  substance  of 
the  gland,  or  in  the  cellular  plane  which  is  interposed  between 
it  and  the  pectoral  muscles.  It  often  happens  that  these 
different  parts  are  all  simultaneously  or  consecutively  affected. 

The  symptoms  of  "  milk  abscess  "  are  well  marked.  There  is 
a  high  degree  of  pyrexia.  The  breast  is  swollen,  hard,  hot,  red, 
painful,  and  exquisitely  tender  to  the  touch. 

Treatment. — ^The  constitutional  treatment  should  be  mildly 
antiphlofjistic.  Tlie  breast  should  be  well  supported  with  a 
bandage  or  handkerchit-f.  If  the  patient  is  robust,  and  the 
inHamrnaticm  very  acute,  leeches  should  be  applied.     In  all  cases 


Bandage  for  both  breasts. 


ACUTE  INFLAMMATION  OF  THE  BEEAST.        273 


poultices  or  fomentations  must  be  constantly  used ;  and  when  re- 
solution has  begun  to  take  place,  the  gland  should  be  gently 
rubbed  with  some  simple  ointment  or  liniment. 

The  secretion  of  milk  is  generally  stopped ;  if,  however,  it 
continues,  a  large  belladonna  plaster  should  be  laid  over  the 
breast  j  and  the  child  should  only  be  allowed  to  suck  the  sound 
breast.  If  the  inflamed  breast  becomes  painfully  distended,  the 
milk  must  be  drawn  off"  by  means  of  a  breast-pump. 

If  suppuration  occurs,  the  matter  should  be  let  out  as  soon  as 
fluctuation  can  be  detected.  The  opening  should  be  made  at  the 
most  dependent  point.  If  the  matter  burrows,  a  counter-open- 
ing will  be  required,  and  in  such  a  case  a  small  drainage-tube  may 
sometimes  be  introduced  with  great  advantage.  If  sinuses  re- 
main, they  should  be  dressed  with  stimulating  lotions,  and  their 
sides  kept  at  rest,  and  in  apposition,  by  equable  pressure.  This 
may  sometimes  be  effected  by  bandaging  the  breast  in  the 
manner  already  described,  or  by  covering  the  sinuses  with  pads 
of  lint  and  strapping  the  breast  with  strips  of  plaster. 

Strapping  the  breast. — When  our  object  is  merely  to  support 
the  breast,  the  strapping  may  be  applied  in  the  following  man- 
ner : — The  surgeon  takes  a  sufficient  number  of  strips  of  adhesive 
plaster,  about  an  inch  and  a  half  broad,  and  long  enough  to  pass 
over  the  breast  and  obtain  a  firm  purchase  at  both  sides.  He 
then  proceeds  to  apply  the  strips  in  regular  order,  laying  the  first 
on  the  patient's  side,  bringing  it  up  under  the  breast,  and  carrj  - 
ing  it  towards  the  opposite  shoulder.  The  others  he  then  applies 
one  above  the  other,  until  he 
has  placed  a  sufficient  number 
to  effect  the  object  he  has  in 
view  (Fig.  121). 

When  the  strapping  is  used 
to  compress  the  breast,  it  is 
better  to  lay  the  alternate  strips 
of  plaster  crosswise.  When  the 
whole  organ  has  been  covered 
in  this  way,  it  may  be  necessary 
to  stretch  a  few  pieces  of  plaster 
in  various  directions,  wherever 
there  is  a  chink  through  which 
the  skin  can  protrude,  or  where 
the  part  seems  to  require 
additional  pressure. 

"  Milk  abscess  "  is  generally  associated  with  an  exhausted  and 
debilitated  state  of  health.  As  soon,  therefore,  as  suppuration  has 
taken  place,  all  lowering  measures  should  be  abandoned,  and  the 


Fig.  121. 


Strapping  the  breast. 


274  DISEASES  OF  TISSUES    AND  OEGANS. 

patient  should  have  a  nutritious  diet,  with  a  moderate  allowance 
of  stimulants.  At  the  same  time  she  should  take  the  mineral 
acids  and  bark,  or  other  strengthening  medicines  (F.  30,  31, 32). 

THE  CHRONIC  V/lATi/lT/tAJfY  OR  ADENOID 
TUMOUR 

is  not  unfrequently  met  with,  and  may  easily  be  mistaken  for 
a  malignant  growth.  It  generally  occurs  in  young  women  under 
thirty,  who  are  otherwise  in  good  health ;  and  it  may  often  be 
traced  to  some  local  source  of  irritation,  such  as  a  blow.  A  portion 
of  the  gland,  generally  at  the  circumference,  enlarges :  there  is 
a  partial  hypertrophy.  A  tumour  is  formed  which  is  hard, 
lobulated,  and  moveable.  It  is  usually  free  from  pain  or  tender- 
ness. Sometimes  it  feels  nodulated,  like  a  bunch  of  grapes. 
Along  with  the  enlargement  of  the  gland-structure,  the  fibrous 
septa  become  hypertrophied,  and  it  is  very  common  to  find  cysts 
developed  in  the  tumour,  either  from  the  areolar  interspaces,  or 
from  obstruction  of  the  milk-ducts  (sero-cystic  tumour).  The 
chronic  mammary  tumour  is  distinguished  by  the  following 
characters  : — It  does  not  affect  the  axillary  glands.  It  does  not 
implicate  the  skin.  It  does  not  impair  the  general  health.  It 
may  remain  stationary  for  years,  and  then  gradually  disappear  ; 
or,  after  a  long  period  of  quiescence,  it  may  suddenly  begin  to 
increase  rapidly  in  size. 

Its  minute  structure  consists  of  the  gland  tissue  greatly  hyper- 
trophied, mixed  with  fibrous  and  areolar  tissue. 

The  treatment  consists  in  regulating  tlie  general  health,  and 
endeavouring  to  bring  about  absorption  by  internal  remedies, 
such  as  bromide  or  iodide  of  potassium  (F.  57,  58,  60),  or  corrosive 
sublimate  (F.  49,  50) ;  or  by  external  applications,  such  as  iodine 
tincture,  or  by  pressure  applied  by  strapping  the  breast  in  the 
manner  above  described  either  with  common  diachylon,  or  the 
emp.  belladonnse,  or  the  emp.  aramoniaci  c.  hydrargyro.  If  there 
is  neuralgic  pain,  anodyne  liniments  should  be  used,  and  sedatives 
or  narcotics  given  internally.  If  there  are  occasional  attacks  of 
inflammation,  a  few  leeches  will  be  found  beneficial.  If  the 
tumour  is  growing  rapidly,  and  threatening  to  ulcerate,  it  should 
be  excised.  In  doing  so,  it  is  not  necessary  to  remove  the  whole 
gland,  but  only  that  portion  of  it  which  is  diseased. 

MAIiIGNiiia-T  TUMOURS   OF  THE   BREAST. 

Besides  the  tumours  of  which  we  have  already  spoken,  the 
breast  is  sometimes  the  seat  of  morbid  growths  of  a  fatty,  fibrous, 
Sarcomatous,  or  syphilitic  kind.  But  by  far  the  greater  number 
of  tumours  in  this  situation  belong  to  the  carcinomatous  class. 


MALIGNANT  TUMOURS   OF  THE  BEEAST.       275 


They  are  chiefly  of  the  scirrhous  and  medullary  varieties.  The 
disease  is  always  primary,  and  is  generally  confined  to  one  breast. 
Sometimes  it  occurs  as  an  infiltration,  but  more  often  as  a  cir- 
cumscribed tumour. 

Scirrhus  is  remarkably  common  in  the  breast  between  the  ages 
of  forty  and  fifty — that  is,  at  the  "  change  of  life." 

It  begins  as  a  small, 
hard     tumour     near     the  Fig.  122, 

centre  of  the  gland.  At 
first  it  is  moveable,  but 
soon  it  becomes  adherent 
to  the  skin  in  front  and  to 
the  pectoral  muscle  behind 
(Fig.  122).  The  nipple 
is  retracted.  There  is  pain 
of  a  darting  character.  The 
axillary  glands  become  en- 
larged. The  skin  ulcerates, 
and  an  oflensive,  exhausting 
discharge  commences. 

Along  with  this  the 
general  health  usually 
sufiers  much.  The  system 
is  deeply  affected  by  the 
local  disease,  constituting 
what  is  sometimes  called 
the  cancerous  cachexia. 
The  growth  of  a  scirrhous 
tumour   of   the    breast    is 

slow,  but  sure.  According  to  Sir  James  Paget  it  tends  to  destroy 
life  in  an  average  period  of  about  four  years.  Sometimes  the 
disease  runs  its  whole  course  in  a  few  months ;  sometimes  it  exists 
for  tw^enty  years.  As  a  general  rule,  the  younger  the  patient  the 
more  unfavourable  is  the  prognosis. 

Medullar ij  cancer,  as  a  primary  aflPection,  is  less  common  than 
scirrhus ;  though  as  a  secondary  growth,  it  is  often  met  with 
after  extirpation  of  a  hard  cancer .^^^  It  occurs  at  an  earlier  age 
than  scirrhus,  grows  rapidly,  and^Ron  forms  a  large,  smooth, 
elastic  tumour  with  dilated  veins  coursing  over  it.  As  it  in- 
creases the  axillary  glands  become  afiected ;  it  attaches  itself  to 
the  subjacent  muscles ;  the  skin  becomes  purple  and  ulcerates, 
and  the  morbid  growth  protrudes  in  fungous  masses.  It  does  not 
infect  the  system  so  deeply  as  scii-rhus,  nor  does  it  produce  the 
same  degree  of  prostration.  The  constitutional  effect  is  not  in 
proportion  to  the   local   manifestation  of  the   disease.      When 

T  2 


Malignant  tumom-  of  the  breast. 


276  DISEASES   OF  TISSUES  AND    OEGANS. 

malignant  disease  occurs  as  a  diffused  infiltration  of  the  tissues,  it 
belongs  to  this  variety.  The  prognosis  in  such  cases  is  very 
unfavourable.  I  have  known  an  instance  which  ran  its  whole 
course  in  seven  weeks :  the  patient  was  a  woman  aged  forty. 

The  male  breast  is  sometimes,  though  very  rarely,  the  seat  of  a 
malignant  tumour.     It  is  usually  scirrhus. 

The  treatment  of  malignant  tumours  of  the  breast  is  unsatis- 
factory. Constitutional  reiuedies  are  of  no  curative  value.  They 
are  of  much  use  in  improving  the  state  of  the  patient's  health, 
and  enabling  her  to  withstand  the  violence  of  the  disease ;  but 
beyond  this  they  are  powerless.  Neither  can  we  boast  of  having 
any  local  means  of  effecting  a  certain  cure.  Entire  removal,  which 
holds  out  the  best  hope,  seldom  does  more  than  relieve  the  more 
urgent  symptoms,  and  prolong  life  for  a  few  months  or  years.  And 
there  are  many  cases  to  which  even  this  remedy  is  inapplicable. 
For  example,  when  the  skin  is  brawny  over  a  large  extent,  when  the 
general  health  is  seriously  impaired,  when  there  is  reason  to  think 
that  internal  organs  are  secondarily  affected,  when  the  tumour  is 
widely  adherent,  or  very  much  ulcerated,  when  both  breasts  are 
diseased,  or  when  the  glands  under  or  above  the  clavicle  are 
enlarged — in  all  these  cases  an  operation  is  forbidden.  On  the 
other  hand,  when  the  tumour  is  of  moderate  size,  moveable,  and 
growing  slowly,  when  the  axillary  glands  are  unaffected,  and  the 
patient's  health  is  not  yet  impaired,  the  results  of  an  operation 
will  probably  be  good.  If  a  scirrhous  cancer  shows  itself  rather 
late  in  life,  say  after  the  age  of  fifty-five,  and  progresses  but 
slowly,  it  may  be  a  question  whether  an  operation  ought  to  be 
recommended.  To  know  exactly  when  to  interfere  in  a  case 
of  this  kind  is  a  difiicult  practical  point.  Again,  should  an 
operation  be  undertaken  if  the  patient  is  pregnant  ?  This  is  a 
question  of  some  difficulty.  As  a  general  rule,  we  may  say 
that  if  she  has  not  yet  "  quickened,"  an  operation  may  be  per- 
formed ;  but  if  she  has  felt  the  movements  of  the  child,  the 
surgeon  had  better  not  interfere.  In  either  case,  the  prognosis  is 
unfavourable,  because  of  the  active  nutritive  changes  that  go  on 
in  the  breast  during  pregnancy. 

Small  tubercles  of  cancer  may  be  removed  either  by  the  knife 
or  by  caustic;  80  also  may  the  chronic  superficial  sores  and 
cracked  nipples,  which  not  unfrequently  give  rise  to  cancer  in  the 
subjacent  gland. 

Equable  pressure  has  occasionally  been  found  to  be  of  great 
service  in  allaying  pain,  and  sometimes  even  in  arresting 
growth. 

Under  any  circumstances,  pending  an  operation,  or  if  an  opera- 
tion is  forbidden,  the  breast  should  be  treated  with  anodyne 


PAEACENTESIS  ABDOMINIS.  277 

lotions  and  ointments ;  and,  if  ulceration  has  taken  place,  poultices, 
either  plain  or  medicated,  should  be  applied. 

If  the  patient  declines  a  cutting  operation,  the  growth  may 
sometimes  be  removed  by  caustics — either  spread  on  the  surface, 
in  the  form  of  a  paste,  or  inti'oduced  into  or  beneath  the  tumour 
in  the  shape  of  "  caustic  arrows.'^  When  caustic  is  to  be  applied, 
the  surgeon  should  take  a  piece  of  thick  leather  plaster,  cut  in  it 
a  hole  of  the  size  of  the  desired  slough,  lay  it  in  the  proper 
situation,  and  then  fill  the  aperture  with  the  caustic.  The 
"  Vienna  paste,"  of  which  the  basis  is  potash  and  lime,  is  one 
of  the  best.  A  few  years  ago  "  Fell's  paste,"  made  of  chloride 
of  zinc,  was  much  in  vogue. 

EXCISION-   OF   THE   BREAST 

is  performed  by  making  two  curved  incisions  including  an  elliptical 
portion  of  skin,  of  which  the  nipple  is  the  centre.  The  amount 
of  skin  removed  must  depend  upon  the  extent  to  which  it  is  in- 
volved in  the  disease.  All  that  is  affected  should  be  taken  away, 
but  no  more.  The  integument  should  be  dissected  back,  so  as  to 
expose  the  whole  anterior  aspect  of  the  tumour.  The  growth 
should  be  lifted  from  its  cellular  bed,  and  the  dissection  carried  on 
under  it,  beginning  from  above  and  proceeding  downwards.  If 
there  are  any  enlarged  glands  in  the  neighbourhood  of  the  tumour, 
they  should  be  removed  at  the  same  time.  The  bleeding  points 
should  be  ligatured,  or  secured  by  torsion,  and  the  edges  of  the 
incision  must  be  carefully  united  by  sutures.  A  large  flat  pad  of 
folded  lint  should  then  be  placed  over  the  seat  of  operation,  and 
retained  by  a  bandage. 

In  operating  upon  a  cancerous  breast,  some  surgeons  take  away 
all  that  is  affected,  but  no  more;  others  think  that,  however 
limited  may  be  the  disease,  the  whole  gland  should  be  removed. 
This  is  probably  the  safer  course. 

FARACEITTESIS  ABBOMIM-IS. 

The  belly  has  sometimes  to  be  tapped  for  ascites,  or  for  ovarian 
dropsy.  In  such  cases  the  abdomen  is  much  distended,  and  there 
is  distinct  fluctuation.  The  patient's  breathing  is  embarrassed, 
and  the  general  health  suffers.  Care  must  be  taken  not  to  mis- 
take a  gravid  uterus,  with  an  unusual  amount  of  liquor  amnii,  for 
an  ovarian  cyst  or  for  ascites. 

When  the  surgeon  is  called  upon  to  tap  the  abdomen,  he  should 
provide  himself  with  a  roller  about  eighteen  inches  broad,  and 
long  enough  to  go  once  and  a  half  round  the  patient's  body. 
Such  a  binder  may  most  conveniently  be  made  by  folding  an 
ordinary  bed-sheet.     When  the  operation  is  about  to  be  performed 


278  DISEASES  OF  TISSUES  AND  ORGANS. 

the  patient  should  be  brought  to  the  edge  of  the  bed,  and  directed 
to  lie  upon  his  back  or  side,  as  may  be  most  convenient ;  and 
then  the  roller  should  be  passed  under  him,  so  that  its  central 
portion  may  be  directly  beneath  the  abdomen.  The  surgeon  then 
folds  the  ends  of  the  binder  across  the  front  of  the  patient's 
body,  and  gives  one  to  each  of  his  assistants,  who  stand  at  the 
opposite  sides  of  the  bed,  and  are  prepared  to  draw  gently,  but 
steadily,  upon  the  bandage,  so  as  to  support  the  abdomen  as  the  fluid 
escapes.  An  incision,  an  inch  long,  is  then  made  through  the  in- 
teguments in  the  middle  line  of  the  body,  and  three  or  four  inches 
below  the  umbilicus.  Through  this  a  trochar  and  canula  is 
pushed  into  the  cavity.  If  the  patient  feels  faint,  the  flow  of 
liquid  may  be  stopped  for  a  time,  and  a  cordial  administered. 
After  the  fluid  has  been  evacuated,  the  pressure  should  be  kept 
up,  while  the  opening  made  by  the  trochar  is  closed  with  adhesive 
plaster  and  a  pad  of  lint.  Then  the  ends  of  the  binder  should 
be  folded  round  the  patient's  body,  and  firmly  pinned  in  that 
situation. 

OVARZAIO-  DISEASE. 

The  ovary  is  often  affected  by  morbid  growths.  These  are 
either  malignant  or  fibrous,  and  are  commonly  associated  with 
cystic  formations  {cystic  disease  of  the  ovary,  ovarian  dropsy). 
These  cysts  appear  generally  to  originate  in  the  Graafian  vesicles 
of  the  ovary,  but  sometimes  they  are  developed  in  the  broad 
ligament.  They  may  bo  single  or  multiple ;  the  tumour  may 
be  unilocular  or  multilocular.  The  contents  of  the  cysts  vary 
extremely.  They  may  be  either  solid  or  fluid.  The  fluid  is  usually 
thick,  viscid,  albuminous,  and  of  a  brownish  or  greenish  colour. 

Ovarian  tumours  sometimes  remain  stationary  for  a  length  of 
time,  but  much  more  commonly  they  go  on  increasing  until  they 
prove  fatal  by  exhaustion,  or  by  interfering  with  the  action  of  the 
viscera. 

Treatment. — Little  or  notliing  can  be  done  by  medical  means. 
If  the  case  is  otherwise  suitable,  the  tumour  may  be  simply 
tapped,  or  tapped  and  injected  with  iodine.  But  it  is  not  often 
that  these  means  are  employed  at  the  present  day.  If  the 
symptoms  are  urgent,  the  question  of  ovariotomy  must  be  enter- 
tained. The  cases  which  are  the  most  favourable  for  this  opera- 
tion are  those  in  which  there  is  but  little  solid  matter,  where 
there  is  a  pedicle  of  some  length,  where  there  are  no  adhesions, 
and  where  the  patient's  general  health  has  not  yet  begun  to  suffer. 
But,  unfortunately,  the  character  of  the  tumour  and  its  con- 
nections are  points  which  it  is  often  difficult,  or  impossible,  to 
ascertain  beforehand  with  accuracy. 


PENETRATING  WOUNDS   OF  THE  ABDOMEN.     279 

Ovariotomy. — An  incision,  three  or  four  inches  in  length,  is 
made  through  the  linea  alba,  between  the  umbilicus  and  the 
pubes,  and  carried  carefully  down  to  the  tumour.  The  hand 
should  then  be  introduced  through  the  opening  to  explore  the 
surface  of  the  tumour,  and  to  ascertain  if  there  are  many  ad- 
hesions. If  there  are  none,  and  the  tumour  consists  of  a  single 
cyst,  it  may  be  tapped,  and  withdrawn  through  the  aperture. 
If  there  are  several  cysts,  they  must  be  tapped  one  after  another, 
and  the  whole  withdrawn.  If,  on  the  other  hand,  there  are 
adhesions,  or  if  the  growth  is  solid,  the  incision  will  have  to  be 
enlarged,  the  adhesions  torn  asunder  or  carefully  divided,  and  the 
tumour  separated  from  its  attachment.  The  pedicle  may  either 
be  drawn  forward,  and  fixed  in  the  wound  by  a  clamp,  or  else 
ligatured,  and  left  in  the  abdominal  cavity — the  ligature  being 
either  cut  otf  short,  or  allowed  to  protrude  through  the  incision. 
When  the  pedicle  is  long,  the  clamp  answers  well.  When  it  is 
short,  probably  "  tying  and  dropping"  is  the  best  course.  The 
noose  of  ligature,  whether  it  be  animal  or  vegetable  tissue,  be- 
comes imbedded  and  absorbed,  and  gives  surprisingly  little 
trouble.  The  wound  in  the  abdominal  parietes  should  then  be 
brought  together  throughout  its  whole  depth  by  quilled  sutures, 
and  the  skin  united  by  a  continuous  suture.  The  abdomen  must 
be  supported  by  a  bandage,  or  by  broad  strips  of  plaster. 

The  after  treatment  must  be  conducted  with  the  utmost  care 
and  vigilance.  The  chief  dangers  to  be  apprehended  are 
secondary  hajmorrhagc,  peritonitis,  and  general  exhaustion. 

The  superficial  wound  is  then  closed  with  sutures,  and  a  ban- 
dage applied  round  the  abdomen. 

PENETRATXXG  "WOUNDS   OF  THE   ABDOMEIT 

are  always  attended  with  danger,  and  require  to  be  carefully 
watched.  If  any  of  the  viscera  are  wounded,  the  shock  will 
probably  be  great.  The  patient  falls  into  a  state  of  collapse, 
w4iich  is  so  far  favourable  that  it  facilitates  the  natural  lisemo- 
static  processes.  The  surgeon  should  not,  therefore,  be  in  a 
hurry  to  bring  about  reaction.  If  one  of  the  large  arteries  is 
divided,  or  if  the  liver  or  spleen  is  wounded,  there  will  be  danger 
of  fatal  haemorrhage.  If  there  is  extravasation  of  bile  or  of 
urine,  peritonitis  is  inevitable.  If  the  intestines  are  injured, 
there  will  probably  be  hsematemesis,  or  melsena.  If  the  kidneys 
are  wounded,  there  will  be  blood  in  the  urine — hsematuria. 

Treatment. — The  most  perfect  rest  and  quietness  should  be 
enforced.  Opium  should  be  given  freely.  The  diet  should  be 
strictly  limited,  and  confined  to  food  which  is  readily  absorbed  by 
the  stomach.     If  inflammation  threatens,  calomel  should  be  com- 


280  DISEASES  OF  TISSUES  AND  OEGANS. 

bined  with  the  opium  (F.  82).  Blood  should  be  drawn  by  the 
lancet  or  by  leeches.  Fomentations  or  water-dressing  should  be 
applied  to  the  abdomen.  Purgatives  must  not  be  given.  If 
need  be,  and  the  circumstances  of  the  case  permit,  an  enema  may 
be  administered  from  time  to  time. 

If  the  bowel  protrudes,  it  should  be  gently  replaced.  If  it  is 
wounded,  and  the  wound  is  a  mere  puncture,  nothing  need  be 
done ;  the  mucous  lining  will  bulge  and  close  the  aperture.  If  it 
is  slit  up,  the  incision  should  be  accurately  brought  together  by 
the  glover's  suture,  using  a  fine  catgut  or  hempen  thread.  If  it 
is  so  extensively  wounded  that  there  is  no  chance  of  union, 
it  should  be  stitched  to  the  margin  of  the  superficial  woiind,  so 
as  to  form  an  artificial  anus.  In  cases  of  this  kind  the  displace- 
ment is  often  not  so  great  as  we  should  have  expected.  The 
contents  of  the  abdomen,  by  the  even  pressure  they  exert,  do 
something  to  prevent  extravasation.  Moreover  the  peritoneum 
pours  out  lymph  freely,  and  repairs  the  damage  that  has  been 
done.  But  whenever  the  abdominal  walls  have  been  wounded, 
it  is  probable  that  a  hernia  will  afterwards  occur  at  the  seat  of 
injury.  The  patient  should  be  warned  of  this  when  he  begins  to 
move  about,  and  supplied  with  a  suitable  bandage  or  truss. 

Injuries  of  this  nature  are  very  apt  to  be  followed  by  peri- 
tonitis. 

PERITOirZTZS 

may  arise  spontaneously ;  but  in  surgical  practice  it  often  occurs 
after  wounds  of  the  abdomen  or  operations  upon  the  abdominal 
organs. 

The  sym'ptoms  of  such  an  attack  are  these  : — The  patient  lies 
on  his  back,  and  relaxes  his  abdominal  muscles  by  drawing  up  his 
knees.  His  breathing  is  chiefly  thoracic.  He  scarcely  ventures 
to  move  his  diaphragm  or  abdominal  muscles.  His  features  are 
pinched ;  his  expression  is  anxious ;  the  pulse  is  small,  hard,  and 
quick  J  the  temperature  raised ;  the  tongue  is  dry,  and  the 
mouth  is  parched.  There  is  frequent  vomiting  j  the  belly  is 
exquisitely  tender,  and  the  bowels  are  constipated. 

Treatment. — Perfect  rest  and  quietness  must  be  secured. 
Opium  should  be  given  in  full  doses,  combined,  if  the  surgeon 
thinks  fit,  with  calomel  (F.  53,  82).  Effervescing  salines  should 
be  prescribed  (F.  35,  68).  Small  pieces  of  ice  should  be  given 
frequently,  to  allay  sickness  and  to  moisten  the  mouth.  Fomenta- 
tions should  be  applied ;  and,  in  some  cases,  if  the  patient 
is  young  and  plethoric,  a  dozen  leeches  may  be  placed  on 
the  abdomen ;  while  enemata  are  administered  occasionally,  as 
the  occasion  requires. 


281 


ZNTTESTIUAIi  OBSTRUCTION'S. 

These  may  be  either  acute  or  chronic,  and  this  distinction  is 
of  great  practical  importance. 

The  free  passage  through  the  bowels  may  be  acutely  ob- 
structed (1)  by  an  internal  hernia,  a  knuckle  of  the  intestine  slip- 
ping through  a  hole  in  the  mesentery  or  omentum,  or  becoming 
constricted  by  a  fibrinous  band ;  (2)  by  intussusception — i.e.,  by 
the  upper  portion  of  the  bowel,  at  some  given  point,  slipping 
within  the  lower  portion;  (3)  by  a  volvulus,  the  bowel  being 
twisted  on  itself ;  (4)  by  inflammation  of  the  intestines. 

Symptoms  of  acute  obstruction. — In  many  instances  the 
patient  is  seized  with  sharp  local  pain,  and  is  aware  that  some- 
thing has  gone  wrong.  With  this  there  is  nervous  shock  and 
depression.  The  bowels'  may  act  slightly,  the  irritation  causing 
them  to  rid  themselves  of  any  accumulation  there  may  be  below 
the  point  of  disease ;  but,  after  that,  there  is  complete  constipa- 
tion. Soon  there  is  vomiting ;  and  ere  long  the  vomited  matters 
become  stercoraceous.  The  belly  is  distended,  the  distension 
being  sometimes  markedly  more  in  one  part  than  in  another. 
Sometimes  the  intestines  can  be  seen  working  under  the  skin, 
and  these  movements  are  attended  by  loud  gurgling  noises.  In 
some  cases  of  intussusception  an  elongated  tumour  may  be  dis- 
tinctly felt,  and  blood  and  mucus  escape  by  the  anus. 

Chronic  intestinal  obstruction  is  usually  the  result  of  (1)  habi- 
tual constipation,  the  impaction  of  faeces  becoming  so  great  as 
to  block  the  passage  altogether ;  (2)  malignant  disease  of  the 
bowels ;  (3)  tumours  of  various  kinds  pressing  upon  the  bowel 
from  outside. 

Symptoms  of  chronic  obstruction. — Constipation  gradually 
increasing  till  it  becomes  complete ;  retching  ;  vomiting,  perhaps 
of  stercoraceous  matters ;  tympanitic  distension  of  the  bowels ; 
exhaustion. 

To  make  an  exact  diagnosis  of  the  cause  of  the  obstruction  is 
often  a  matter  of  great  difficulty.  The  surgeon  should  be  care- 
ful to  see  that  there  is  no  external  hernia.  Especially  he  should 
look  for  the  rarer  kinds  of  hernia,  such  as  the  obturator. 

The  treatment  must  vary  with  the  cause  of  the  obstruction. 
If  there  is  reason  to  think  that  it  depends  upon  inflammation  of 
the  bowels,  medical  means  may  suffice  for  its  relief.  Calomel 
and  opium  should  be  prescribed,  and  fomentations  applied.  If 
the  obstruction  depends  upon  intussusception  or  volvulus,  the 
surgeon  may  be  fortunate  enough  to  remedy  it  by  inflation — i.e., 
by  slowly  distending  the  bowels  with  air  by  means  of  a  suitable 


282  DISEASES   OF  TISSUES   AND  OEGANS. 

pair  of  bellows.  If  these  measures  fail,  or  if  the  obstruction  de- 
pends upon  an  internal  hernia  or  a  constricting  band,  the 
patient's  only  hope  lies  in  an  operation.  If  the  obstruction  is 
in  the  colon,  colotomy  (Calissen's  or  Amussat's  operation)  must 
be  performed.  If  the  obstruction  is  situated  in  the  small  intes- 
tines, gastrotomy  (abdominal  section)  will  be  required. 

Colotomy  consists  in  opening  the  colon  either  in  the  right  or 
left  loin.  The  surgeon  defines  the  outer  border  of  the  quadratus 
lumborum  muscle,  for  this  line  indicates,  with  tolerable  exacti- 
tude, the  situation  of  the  colon.  He  then  makes  an  incision 
four  or  five  inches  long,  beginning  near  the  spine  and  passing 
obliquely  downwards  and  forwards,  parallel  to  the  crest  of  the 
ilium.  The  tissues  must  be  divided  cautiously,  the  transversalis 
fascia  being  slit  up  on  a  director  :  the  bowel  is  here  uncovered  by 
peritoneum.  Sometimes,  when  it  is  distended,  it  presents  itself 
to  view  at  once;  sometimes  it  needs  to  be  sought  for  carefully. 
When  it  is  found,  it  should  be  drawn  gently  forward,  two  double 
threads  passed  through  it,  and  then,  when  it  is  securely  held, 
an  opening  made  in  it.  Sometimes  a  gush  of  fsecal  matter 
takes  place ;  sometimes  little  or  nothing  escapes  at  the  time. 
Before  the  operation  is  concluded  the  edges  of  the  aperture 
must  be  stitched  to  the  integument. 

Gastrotomy  consists  in  opening  the  peritoneal  cavity,  in  order 
to  search  for  the  cause  of  obstruction.  If  there  is  an  obvious 
tumour,  as  sometimes  happens  in  cases  of  intussusception,  the 
surgeon  should  be  guided  by  it  in  making  his  incision.  But  if 
there  is  no  such  indication,  he  should  make  his  incisions  down  the 
linea  alba,  divide  the  tissues  w^ith  caution,  slit  up  the  peri- 
toneum on  a  director,  and  then  trace  the  bowel  in  a  systematic 
manner,  either  upwards  or  downwards,  till  he  comes  to  the  ob- 
struction. The  diflSculties  of  this  operation  are  often  increased 
by  the  protrusion  of  the  intestines.  The  surgeon  should,  there- 
fore, be  careful  to  have  them  held  back  by  assistants.  When 
the  operation  has  been  concluded,  the  edges  of  the  wound  should 
be  brought  together  with  stitches,  and  the  belly  supported  by 
strips  of  plaster  or  a  bandage. 

Mr,  Bellamy  has  lately  reported  to  the  Clinical  Society  a  case 
in  which  the  obstruction  was  of  a  most  unusual  kind.  A  por- 
tion of  small  intestine  had  become  invaginated  in  the  anterior 
wall  of  the  rectum,  apparently  separating  its  muscular  fibres, 
and  pushing  the  rectal  mucous  membrane  before  it.  It  completely 
obstructed  the  lumen  of  the  rectum.  All  attempts  to  dislodge  it 
by  the  rectum  were  useless,  so  Mr.  Bellamy  opened  the  ab- 
dominal  cavity  and  withdrew  the  invaginated  gut.  {Brit.  Med. 
Jour.,  March  8,  1879.) 


283 


ARTZFXCIAI.  AITVS 

signifies  an  unnatural  opening  into  the  intestinal  canal  for  the 
discharge  of  faeces.  It  may  be  made  by  the  surgeon,  or  it  may 
be  the  result  of  a  wound,  of  an  abscess,  of  ulceration,  or  of  the 
sloughing  of  a  strangulated  hernia.  When  the  communication 
with  the  bowel  is  but  slight,  and  the  contents  merely  ooze  out,  it 
is  called  a  "  faecal  fistula."' 

When  the  artificial  anus  is  in  the  upper  part  of  the  small 
intestine,  life  can  only  be  prolonged  for  a  time.  The  patient 
must  gradually  die  of  starvation  by  escape  of  the  chyle.  But 
when  the  aperture  is  in  the  large  intestine,  it  is  compatible  with 
a  fair  share  of  health,  though  it  must  always  be  a  source  of  great 
discomfort. 

Treatment. — In  all  affections  of  this  kind  the  patient's  strength 
must  be  supported,  the  wound  kept  very  clean,  and  the  margins 
smeared  with  simple  ointment  or  vaseline  to  prevent  excoria- 
tion. A  fa3cal  fistula  will  probably  close  of  itself,  and  heal  over. 
If  the  case  is  one  of  artificial  anus,  and  the  bowel  is  pervious, 
an  attempt  may  be  made  to  unite  the  edges  of  the  wound.  It 
generally  happens,  however,  that  after  the  artificial  anus  has  existed 
for  a  short  time,  the  lower  and  unused  part  of  the  gut  becomes 
contracted.  Moreover,  the  wall  of  the  bowel  opposite  the  aper- 
ture protrudes,  and  forms  a  septum,  dividing  the  part  which  is 
traversed  by  the  faeces  from  the  part  that  is  not.  This  is  one 
great  obstacle  to  re-establishing  the  natural  channel.  Dupuytren 
proposed  to  get  rid  of  the  septum  by  compressing  it  between  the 
blades  of  a  forceps  until  it  sloughed  away;  after  which  an  attempt 
might  be  made  to  close  the  supei-ficial  wound. 

HERiriA 

signifies  a  protrusion  of  the  contents  of  one  of  the  natural  cavi- 
ties. Thus  we  speak  of  hernia  of  the  brain,  of  the  lung,  and  of 
the  intestines.  But  when  the  term  stands  alone  it  is  taken  to 
mean  the  protrusion  of  a  portion  of  the  intestines  through  the 
walls  of  the  abdominal  cavity  (rupture) ;  such  protrusions  being 
by  far  the  most  common  hernise  that  are  met  with  in  adult  life. 
Hernise  are  variously  classified.  If  we  look  to  the  seat  of  the 
protrusion,  we  speak  of  inguinal,  femoral,  umbilical,  dia'phrag- 
matic,  and  obturator  hernia.  If  we  consider  their  pathology, 
we  describe  them  as  reducible,  irreducible,  incarcerated,  or 
strangulated.  According  to  their  anatomical  relations,  they  are 
divided  into  congenital  and  infantile;  and  according  to  their 
contents,  into  enterocele,  epijplocele,  &c. 


284  DISEASES  OF  TISSUES  AND  ORaANS. 

Sernia  cerebri  has  been  explained  in  speaking  of  wounds  of 
the  brain,  and  diaphragmatic  and  obturator  hernise  are  of  such 
rare  occurrence  that  I  need  not  do  more  than  mention  them. 

Predisposing  causes  of  abdominal  hernia. — Whatever  tends 
to  weaken  the  abdominal  walls — e.g.,  congenital  deficiency  of 
muscular  or  tendinous  structures,  penetrating  wounds,  or  abscess 
in  the  parietes — predisposes  to  hernia. 

Exciting  causes. — Among  the  exciting  causes  of  hernia  may 
be  mentioned  whatever  makes  pressure  upon  the  weakened  part 
of  the  parietes,  as  excessive  crying  in  infants,  coughing,  strain- 
ing at  stool  or  in  micturition,  violent  exertion,  riding,  leaping,  &c. 

The  coverings  of  a  hernia  differ  with  its  precise  situation.  In 
almost  all  cases  it  has  a  sac,  formed  by  the  parietal  layer  of  peri- 
toneum, which  it  carries  before  it.  The  cases  in  which  there  is 
no  sac  are  rare.  They  are  the  hernige  which  follow  penetrating 
wounds,  and  the  protrusions  of  those  viscera  which  are  only  par- 
tially covered  by  peritoneum.  With  these  exceptions,  every 
hernia  is  invested  by  a  sac  of  peritoneum.  That  part  of  the 
sac  which  is  at  the  point  of  protrusion  is  called  the  necJc,  while 
the  rest  is  termed  the  body.  The  neck  is  often  the  seat  of  con- 
striction in  cases  of  strangulated  hernia. 

Diagnosis  of  hernia. — The  tumour  has  come  suddenly,  per- 
haps while  the  patient  was  making  an  unusual  exertion.  It  has 
increased  from  within  outwards.  It  is  not  persistent,  but  retires 
when  the  patient  lies  down,  and  appears  again  when  he  gets  up. 
It  is  situated  at  one  of  the  natural  apertures  in  the  abdominal 
walls.  It  is  regular  in  outline,  circumscribed,  pyriform,  free 
from  pain  or  tenderness,  and  does  not  implicate  the  skin.  If  it 
is  composed  of  omentum,  it  is  doughy  to  the  touch ;  but  if  it 
contains  bowel  and  fluid,  it  may  be  tense,  elastic,  and  gurgling. 
An  impulse  can  be  communicated  to  it  by  coughing ;  it  can  be 
reduced  by  making  the  patient  lie  down,  and  using  a  little  mani- 
pulation, technically  called  the  taxis.  Such  are  the  characteristics 
of  an  ordinary  reducible  hernia. 

A  rupture  is  said  to  be  reducible  when  it  can  be  returned 
without  diflflculty.  When  it  is  permanently  protruded,  and  can- 
not be  returned,  but  gives  rise  to  no  urgent  symptoms,  it  is 
termed  irreducible.  This  state  of  things  is  apt  to  arise  when 
the  sac  becomes  adherent  to  the  tissues  which  cover  it  on  the  one 
hand,  and  to  the  viscera  it  contains  on  the  other  :  or  it  may  be 
due  to  the  deposit  of  fat  in  a  descended  omentum.  Irreducible 
herniffi  are  always  attended  with  inconvenience,  and  they  are 
apt  to  cause  irregularity  of  the  bowels,  with  derangement  of  the 
digestive  organs.  Moreover,  they  are  very  liable  to  become 
strangulated  from  slight  causes. 


HERNIA.  285 

When  ail  irreducible  hernia  becomes  temporarily  obstructed 
by  accumulation  of  faeces  or  of  gas,  but  without  any  urgent 
symptoms,  it  is  said  to  be  incarcerated.  When  the  passage  of 
faeces  is  interrupted,  such  interruption  being  attended  by  acute 
inflammatory  symptoms,  the  hernia  is  said  to  be  strangulated. 
Incarceration  is  often  a  step  towards  strangulation.  If  acute 
symptoms  supervene  upon  an  incarcerated  hernia,  it  becomes 
strangulated. 

With  these  general  remarks  I  shall  proceed  to  speak  in  detail 
of  some  of  the  commoner  varieties  of  hernia. 

And  first  of  inguinal  hernia,  which  presents  itself  under  two 
principal  forms,  the  oblique  and  the  direct. 

Oblique  inguinal  hernia  is  the  name  applied  to  that  variety 
in  which  the  protrusion  orginates  at  the  internal  abdominal 
ring,  on  the  outer  side  of  the  deep  epigastric  vessels,  travels 
obliquely  along  the  whole  length  of  the  inguinal  canal,  and 
appears  at  the  external  abdominal  ring.  The  bowel  follows  the 
course  of  the  spermatic  cord.  This  is  the  most  common  rupture 
that  is  met  with  in  the  male. 

When  the  intestine  is  lodged  in  the  inguinal  canal,  and  has 
not  yet  made  its  way  through  the  external  ring,  it  is  called  a 
bubonocele.  After  it  has  passed  the  external  ring,  it  gradually 
protrudes  into  the  scrotum  or  labium. 

Bubonocele  may  have  to  be  distinguished  from  undescended 
testicle.  In  the  latter  case  the  testis  is  absent  from  the  scrotum, 
and  there  is  sickening  pain  upon  pressing  upon  the  tumour. 

The  coverings  of  an  oblique  inguinal  hernia  are,  from  without 
inwards  :  (1)  skin,  (2)  superficial  fascia,  (3)  inter-columnar  fascia, 
(4)  cremasteric  fascia,  (5)  fascia  propria  (infundibuliform)  derived 
from  the  fascia  transversalis,  (6)  sac. 

The  hernial  protrusion  lies  in  front  of  the  spermatic  cord,  and 
the  neck  of  the  sac  is  just  outside  the  deep  epigastric  vessels. 

Congenital  hernia. — When,  from  imperfect  foetal  development, 
the  prolongation  of  the  peritoneum,  which  goes  to  form  the  tunica 
vaginalis,  is  not  closed,  the  intestine  makes  its  way  along  the 
pervious  canal  into  the  tunica  vaginalis,  and  comes  into  imme- 
diate contact  with  the  testis.  A  congenital  hernia  has  no  proper 
sac ;  its  sac  is  the  parietal  layer  of  the  tunica  vaginalis. 

Infantile  hernia  occurs  in  cases  where  the  pouch  of  peritoneum, 
which  goes  to  form  the  tunica  vaginalis,  is  separated  from  the 
general  cavity  of  the  peritoneum,  but  still  remains  open  to  a 
higher  point  than  usual.  When  this  happens,  and  the  intestines 
protrude  in  the  ordinary  way  (as  they  are  very  apt  to  do  under 
such  circumstances),  we  have  the  condition  known  as  infantile 
hernia.     The   rupture    insinuates     itself  behind   the  elongated 


286  DISEASES   OF  TISSUES  AND  ORGANS. 

tunica  vaginalis.  It  has,  therefore,  as  it  were,  a  double  sac — a 
proper  sac  derived  from  the  peritoneum,  and  a  secondary  sac 
formed  by  the  layers  of  the  tunica  vaginalis,  which  are  com- 
pressed in  front  of  the  proper  sac.  In  cases  of  this  sort,  the 
tunica  vaginalis  is  very  prone  to  become  inflamed,  and  distended 
with  fluid  (hydrocele). 

Direct  inguinal  hernia  originates  on  the  inner  side  of  the  deep 
epigastric  vessels,  immediately  behind  the  external  abdominal 
ring.  It  either  bursts  through,  or  pushes  before  it,  the  con- 
joined tendon.  It  then  presents  itself  at  the  external  ring,  and 
makes  its  way  gradually  down  to  the  scrotum  or  labium.  Its 
coverings  differ  from  those  of  the  oblique  inguinal  hernia  in  that 
it  lacks  the  cremasteric  fascia ;  but  sometimes  (as  we  have  said) 
it  has  a  tunic  formed  by  the  conjoined  tendon. 

Diagnosis  of  inguinal  hernia. — It  is  often  impossible  to  dis- 
tinguish between  a  direct  and  an  oblique  inguinal  hernia.  In 
recent  cases,  the  diagnosis  may  be  made  by  attending  to  the 
situation  and  direction  of  the  tumour;  or  by  restoring  the 
intestine,  and  then  insinuating  the  finger,  and  examining  the 
anatomical  relations  of  the  passage. 

Hernia  and  hydrocele  may  be  distinguished  by  attending  to 
the  following  characteristics.  Hernia  begins  from  above,  is 
opaque,  does  not  fluctuate,  does  not  obscure  the  testicle,  receives 
an  impulse  on  coughing,  and  can  generally  be  reduced  by  making 
the  patient  assume  the  horizontal  position.  Hydrocele  begins 
from  below,  is  translucent,  receives  no  impulse  on  coughing, 
fluctuates,  obscures  the  testicle,  and  does  not  disappear  when  the 
patient  lies  down.  The  two  conditions,  however,  not  unfre- 
quently  coexist. 

Varicocele  may  be  mistaken  for  rupture.  The  best  test  is  to 
make  the  patient  lie  down,  when  the  swelling,  of  whichever 
nature,  will  disappear  ;  the  surgeon  then  presses  his  finger  on 
the  external  ring,  and  orders  the  patient  to  stand  up ;  if  it  is  a 
rupture,  it  will  not  descend,  whereas  if  it  is  a  varicocele,  it  will 
quickly  show  itself. 

Femoral  hernia  passes  through  the  crural  ring,  beneath 
Poupart's  ligament.  When  the  patient  stands  erect,  the  neck  of 
the  sac  has  in  front  of  it  Poupart's  ligament,  behind  it  the  pec- 
tineus  muscle  and  the  pubes ;  on  its  inner  side  Gimbernat's  liga- 
ment ;  and  on  its  outer  side,  the  femoral  vessels  in  their  sheath. 
The  protrusion  takes  place  into  the  crural  canal,  that  is  to  say, 
into  the  innermost  compartment  of  the  crural  sheath.  When 
the  bowel  reaches  the  saphenous  opening  in  the  fascia  lata,  it 
comes  forward  beneath  the  skin;  then,  instead  of  descending 
down  the  thigh,  it  makes  its  way  upwards,  so  that  the  tumour  is 


HERNIA.  287 

doubled  upon  itself,  the  neck  of  the  sac  being  beneath  Poupart's 
ligament,  while  its  fundus  is  immediately  over  it.  It  is  impor- 
tant to  notice  this,  because  in  all  attempts  at  reduction  the  force 
should  be  applied  in  the  opposite  directions,  that  is  to  say,  down- 
wards, inwards,  and  upwards. 

The  coverings  of  a  femoral  hernia  are,  from  without  inwards; 
(1)  skin,  (2)  superficial  fascia,  (3)  cribriform  fascia,  (4)  crural 
sheath,  (5)  septum  crurale,  (6)  sac. 

This  variety  of  hernia  is  most  common  in  women  on  account 
of  their  greater  breadth  between  the  hips. 

Femoral  hernia  may  be  distinguished  from  inguinal  by  observ- 
ing the  relative  position  of  Poupart's  ligament. 

From  a  varicose  condition  of  the  superficial  veins  of  the  thigh 
it  may  be  diagnosed,  by  making  the  patient  lie  down  ;  and  then, 
when  the  swelling  has  subsided,  placing  the  thumb  firmly  on  the 
crural  ring.  In  such  circumstances,  a  hernia  cannot  descend, 
whereas  a  varicose  tumour  soon  reappears. 

From  psoas  abscess  it  may  be  distinguished  by  the  history  of 
the  case,  and  the  absence  of  fluctuation. 

From  enlarged  lymphatic  glands  there  may  be  more  difficulty 
in  making  the  diagnosis.  The  history  of  the  case,  and  the  pre- 
sence, or  absence,  of  a  cause  for  the  glandular  enlargement, 
are  the  points  that  must  guide  us. 

The  treatment  of  these  various  forms  of  hernia  may  conve- 
niently be  considered  together.  When  a  rupture  descends,  the 
surgeon  should  reduce  it  with  as  little  delaj-  as  possible,  endea- 
vouring at  the  same  time  to  discriminate  accurately  to  what 
variety  it  belongs.  This  is  not  always  easy,  but  it  is  desirable,  if 
possible,  because  the  truss-pad  is  sometimes  made  to  vary  in 
shape  according  to  the  nature  of  the  case. 

For   all  ordinary  hernite  the  common  truss,  or,  as  it  is  some- 
times called,   Hart's  truss,  is  perhaps  better   than  any  of  the 
numerous  patent  instruments  which 
have  been  invented.     It  consists  of  ^  ^S-  12o. 

a    pistol-shaped  pad  which  covers      _„^<rTZIIvr —        .— ^^--"^t"^ 
the  hernial    opening,   and   a    steel    irj/       "■^^^^^^^^^.^i**'  ^s\ 

spring    which    passes    round     the   '^J  >J 

patient's  body,    and  is    affixed   by       7^5^^^  _^>^^ 

means  of  a  short  strap  to  a  stud  on  i^^  /^F*^ 

the  back  of  the  pad.     Sometimes  an        i|        /.•/  vi 

under-strap  is  added    which    com-         ^"^.^x  ^ 

mences  at  the   back  of  the  truss.    The  common  truss  (Hart's), 
passes  under  the  perineum,  and  is 

attached   in    front   to    the   stud  on    the   pad    (Fig.    123).      In 
applying  the  truss  the  surgeon  should  first  place  his  patient  in 


288  DISEASES   OF  TISSUES  AND  ORGANS. 

the  recumbent  posture,  and  ascertain  that  the  rupture  is  entirely 
reduced.  He  should  then  stretch  the  spring  round  the  wearer's 
hips,  adjust  the  pad  upon  the  hernial  opening,  and  secure  the 
strap  to  the  stud.  When  the  patient  stands  up,  a  little  further 
adjustment  may  perhaps  be  wanted,  and  the  surgeon  may  have 
to  shift  the  strap  from  one  button-hole  to  another,  before  he 
brings  the  instrument  into  a  position  which  controls  the  rupture, 
and  is  at  the  same  time  comfortable  to  the  wearer. 

Coles's  truss  consists  of  a  steel  spring,  which  goes  half  way 
round  the  body,  from  the  seat  of  rupture  to  the  spine.  At  each 
end  of  the  spring  there  is  a  pad — a  large  flat  one  which  bears 
against  the  spine,  and  a  convex  one  which  covers  the  hernial 
opening.  The  hernial  pad  is  hard  and  unyielding,  being  made  of 
oin  covered  with  flannel  or  leather ;  but  a  certain  amount  of 
elasticity  is  given  to  it  by  a  spiral  spring  which  is  placed  within 
it.  The  principal  objection  to  this  truss  is  its  convex  pad,  which 
has  a  tendency  in  some  cases  to  enlarge  the  hernial  opening ; 
otherwise  it  is  a  light  and  convenient  instrument. 

Salmon  and  Ody's  truss  has  a  steel  spring,  which  goes  three- 
quarters  of  the  way  round  the  body — from  the  groin  where  the 
rupture  is  situated,  across  the  pubes,  and  round  the  hips  to  the 
spine.  The  hernial  pad,  which  is  slightly  convex,  is  attached  to 
the  spring  by  means  of  a  ball-and-socket  joint,  and  this  adapts 
itself  to  the  movements  of  the  patient's  body. 

The  peculiarity  of  Egg's  truss  consists  in  its  strong  steel 
spring,  which  is  said  to  be  made  out  of  old  sword  blades.  The 
spring  goes  completely  round  the  waist,  and  is  bent  to  a  large 
curve,  so  as  nearly  to  follow  the  outline  of  the  patient's  body.  A 
very  slight  degree  of  pressure  from  a  strong  spring,  such  as  this, 
serves  to  restrain  the  rupture,  and  to  keep  the  instrument  in  its 
place.  Indeed,  Egg's  truss  may  be  said  to  act  rather  by  sup- 
porting the  abdominal  walls  than  by  making  pressure  upon  them. 
Any  kind  of  pad  may  be  fitted  to  one  of  these  trusses. 

The  Mocmain  lever  truss  has  two  chief  characteristics — (1) 
The  pad  is  stufied  with  a  peculiar  material  known  as  "  Moc- 
main"— a  vegetable  substance,  which  has  a  silky  texture  and  a 
remarkable  degree  of  elasticity ;  and  (2)  the  spring-force  is 
applied  by  means  of  a  lever,  which  is  placed  at  the  back  of  the 
pad,  so  that  the  steel  girdle  is  altogether  dispensed  with.  A 
leathern  belt  encircles  the  waist,  and  supports  the  pad ;  while  a 
strap  passes  under  the  perineum  from  behind  forwards,  and  is 
affixed  to  the  lever.  It  is  upon  the  tension  of  this  under-strap 
that  the  pressure  upon  tlie  hernial  opening  depends ;  and  hence 
arises  the  chief  objection  to  these  trusses,  for  when  the  thigh  is 
flexed,   as   in   going  upstairs,   the   under-strap   is   relaxed,  the 


HEENIA. 


289 


Fig.  124. 


Matthews'  plated  truss. 


pressure  upon  the  lever  diminished,  and  then  the  rupture  may 
make  its  escape  behind  the  pad. 

Besides  these  there  are  various  other  patent  trusses,  which 
may  be  found  useful  in  particular  cases,  but  those  we  have  men- 
tioned are  the  best  known.  We  must  not,  however,  leave  this 
subject  without  drawing  attention  to  the  plated  truss  made  by 
Matthews  Brothers,  of  Carey  Street.  This  instrument  has  an 
elegant  appearance,  besides  the 
great  recommendation  of  resist- 
ing the  eifects  of  the  perspiration, 
and  requiring  no  covering  of 
leather  or  calico.  The  spring 
itself  is  as  delicate  as  is  com- 
patible with  the  amount  of 
strength  which  is  required  to  fix 
the  truss  in  its  place  without  any 
other  fastening  (Fig.  124),  A 
truss  of  this  description,  fitted  with  one  of  Mr.  Wood's  pads,  is 
perhaps  the  best  appliance  of  the  kind  that  modern  science  and 
skill  have  devised. 

Mr.  Wood  has  introduced  truss-pads  for  cases  of  inguinal 
hernia  which  are  intended  to  bear  upon  the  margins  of  the  hernial 
opening,  and  not  to  protrude  into 
the  aperture  itself,  as  the  ordinary 
convex  ones  are  apt  to  do.  Mr. 
Wood's  pad  for  an  oblique  inguinal 
hernia  is  shaped  like  a  horseshoe 
(Fig.  125,  a),  whereof  the  expanded 
portion  presses  upon  the  internal 
opening  of  the  canal;  while  the 
outer  limb  lies  along  Poupart's 
ligament,  and  the  inner  one  along  the  internal  pillar  of  the 
ring.  By  this  means  firm  pressure  may  be  made  upon  the 
sides  of  the  hernial  opening,  while  a  space  is  left  for  the  passage 
of  the  spermatic  cord  and  vessels. 

For  direct  inguinal  hernia  Mr.  Wood  uses  a  circular  pad,  with 
a  hole  in  the  centre  (Fig.  125,  h) — the  circle  following  the 
margins  of  the  opening,  and  making  such  firm  backward  pressure, 
and  so  stretching  the  skin,  that  the  rupture  cannot  escape. 

For  femoral  hernia  Mr.  Wood  recommends  a  pad  which  is  oval  in 
outline,  and  which  has  a  flat  surface  that  is  placed  against  the  front 
opening  of  the  crural  canal,  while  the  upper  edge  is  rounded  to 
support  Poupart's  ligament,  and  the  lower  bevelled  ofi"  to  fit  the 
saphenous  opening. 

Mr.  Wood's  pads  are  generally  made  in  some  hard,  smooth 

TJ 


Fig.  125. 


Wood's  truss-pads. 


290  DISEASES  OF  TISSUES  AND  ORGANS. 

material,  such  as  boxwood  or  vulcanite ;  sometimes,  however,  they 
are  fitted  with  small  air  or  water  cushions ;  but  in  any  case  they 
are  shaped  so  as  to  adapt  themselves  to  the  anatomical  require- 
ments of  each  variety  of  rupture. 

We  may  here  add  a  few  general  remarks  applicable  alike  to 
all  trusses.  After  a  truss  has  been  adjusted  by  the  instrument 
maker,  the  surgeon  should  examine  it  himself,  and  see  that  it  fits 
the  patient  properly,  and  that  it  keeps  its  place  under  all  ordinary 
movements.  Moreover,  he  should  take  care  that  the  spring  is 
strong  enough  to  control  the  rupture.  With  this  view  he  should 
direct  the  patient  to  stand  up,  with  his  legs  apart,  and  to  cough 
several  times  in  rapid  succession.  If  the  bowel  does  not  protrude 
under  this  test,  the  surgeon  may  feel  satisfied  that  the  spring 
will  bear  all  the  pressure  that  is  likely  to  be  put  upon  it.  The 
truss  generally  requires  to  be  covered  throughout  with  leather  or 
calico,  to  prevent  it  from  being  affected  by  the  perspiration. 
It  should  be  worn  constantly  during  the  day — being  put  on  before 
the  patient  rises  from  bed  in  the  morning,  and  not  laid  aside 
until  he  lies  down  at  night.  If,  as  in  the  case  of  children,  the 
instrument  is  used,  not  merely  as  a  precautionary  measure,  but 
also  with  the  view  of  producing  a  radical  cure,  it  will  be  all  the 
better  if  the  patient  will  consent  to  wear  it  by  night  as  well  as 
by  day.  It  is  sometimes  well  for  a  patient,  though  ruptured  only 
on  one  side,  to  wear  a  double  truss ;  for  there  is  often  a  weak- 
ness of  the  corresponding  region  on  the  opposite  side  of  the  body ; 
and  when  one  groin  is  compressed,  a  greater  strain  is  thrown 
upon  the  other,  so  that  it  is  apt  to  give  way. 

If  the  skin  becomes  chafed  it  should  be  bathed  with  a  little 
eau-de-Cologne  or  brandy,  or  with  a  spirituous  lotion  (F.  21), 
and  then  carefully  dried  with  a  soft  towel,  and  dusted  over  with 
violet  powder  or  French  chalk. 

If  a  patient  presents  himself  to  the  surgeon  with  a  reducible 
hernia,  and  a  truss  cannot  at  once  be  provided,  the  ordinary  spica 
bandage  may  be  applied  over  a  pad  by  way  of  a  temporary 
expedient  (see  Fig.  155) ;  but  care  should  be  taken  to  explain 
to  the  patient  that  his  life  is  in  jeopardy  as  long  as  he  is  going 
about  without  a  proper  truss. 

In  children  we  may  hope  to  obtain  a  cure  by  the  habitual  use 
of  a  truss ;  but  in  adults  such  a  result  cannot  be  expected. 
Here  the  truss  is  a  mere  palliative,  and  if  we  desire  to  effect  a 
radical  cure,  it  must  be  by  the  performance  of  an  operation. 
Operations  for  the  radical  cure  of  hernia  proceed  upon  two  prin- 
ciples. They  either  aim  at  invaginating  the  skin,  superficial 
fascia  and  sac,  so  as  to  plug  theopening  through  which  the  hernia 
passes  (Wiitzer's  operation)  j  or  else,  after  invaginating  the  sac  and 


HEENIA. 


291 


Fiff.  126. 


fasc'iM,  the  sides  of  the  aperture  are  brought  together  by  means  of 
subcutaneous  stitches,  and  held  in  that  position  until  a  sufficient 
amount  of  adhesive  inflammation  has  taken  place  (Wood's).  But 
I  am  inclined  to  agree  with  Mr.  Bryant  that  "  where  a  hernia  can 
be  kept  up  by  a  truss,  and  the  patient  is  likely  to  remain  in  a 
civilized  counti'y  where  trusses  can  be  obtained,  any  operation  for 
the  radical  cure  is  an  unjustifiable  one"  ("  Surgery,"  p.  358). 

If  the  hernia  is  found  to  be  irreducible,  the  patient  should  be 
instructed  to  wear  a  bag-truss  with  a  hollow  pad  which  accurately 
fits  the  protrusion,  so  as  to  prevent  its  increase.  If  the  hernia 
becomes  incarcerated,  the  treatment  must  consist  in  rest  in  the 
horizontal  position,  fomentations  or  iced  applications,  clysters,  and 
the  taxis. 

If  the  rupture  is  strangulated,  the  symptoms  are  urgent ;  and 
the  treatment  must  be  prompt  and  decided. 

Symptoms  of  strangulated  hernia. — The  patient  is  restless  and 
uneasy  ;  his  features  are  pinched,  and  his  expression  anxious.  He 
complains  of  twisting  pain  at  the  umbilicus ;  the  bowels  are  con- 
stipated ;  there  is  nausea  and  vomiting.  After  a  time  the  matter 
which  is  thrown  up  becomes  feculent,  stercoraceous.  The  pulse 
is  hard,  small,  and  frequent; 
gradually  becoming  weak  and  flicker- 
ing. The  tumour,  which  at  first  is 
neither  painful  nor  tender,  becomes 
by  degrees  tense  and  exquisitely  sensi- 
tive. These  symptoms  gradually 
become  aggravated,  and  the  patient 
grows  more  and  more  exhausted.  I 
have  reported  a  case  in  which  the 
patient — a  middle-aged  woman — 
positively  refused  to  have  any  opera- 
tion performed,  and  died  on  the 
twenty-fourth  day  (Lancet,  May, 
1870).  If  the  local  pain  and  tender- 
ness suddenly  cease,  if  the  tumour 
becomes  doughy,  emphysematous, 
and  purple,  if  the  patient  expresses 
himself  as  much  relieved — these 
signs,  taken  together,  indicate  that 
gangrene  has  commenced,  and  they 
are  generally  followed  by  speedy 
death. 

But  it  sometimes  happens  that, 
though  the  hernia  and  its  cover- 
ings slough,  death  does   not  follow. 


Strangulated  congenital 
hernia. 


The  mortified    parts  are 
u  2 


292  DISEASES   OF  TISb'UES  AND  OEGANS. 

thrown  off,  an  opening  into  the  bowel  is  established,  there  is  a 
free  discharge  of  fseces,  the  urgent  symptoms  subside,  and  the 
patient  gradually  rallies  from  the  state  of  prostration.  The  com- 
munication with  the  bowel  remains,  and  must  be  subsequently 
treated  as  an  artificial  anus. 

Fig.  126  represents  a  large  congenital  hernia  which  had  be- 
come strangulated.  The  hour-glass  shape  is  very  characteristic 
of  the  congenital  variety.  The  constriction  marks  the  point 
where  the  prolongation  of  the  peritoneum  which  goes  to  form  the 
tunica  vaginalis  has  been  imperfectly  closed.  In  this  instance 
the  patient  was  a  man  aged  forty-four.  An  operation  was  per- 
formed for  the  relief  of  the  strangulated  gut,  and  about  thirty 
inches  of  bowel  were  returned,  besides  apiece  of  omentum.  The 
portion  of  bowel  which  was  lodged  at  the  bottom  of  the  sac, 
below  the  hour-glass  contraction,  was  intensely  congested.  The 
patient  died  on  the  third  day  after  the  operation. 

Treatment. — In  the  treatment  of  strangulated  hernia  time  is 
of  great  importance.  The  patient  should  at  once  be  placed  in 
the  horizontal  position,  with  his  knees  drawn  up,  so  as  to  relax 
the  abdominal  muscles.  The  taxis  should  then  be'used — that  is 
to  say,  the  surgeon  should  endeavour  to  restore  the  protruded 
viscera  by  manipulation.  With  this  view,  he  grasps  the  body 
of  the  tumour  with  one  hand,  and  while  steadily  compressing  it 
he  pushes  it  towards  the  aperture,  through  which  it  emerged. 
At  the  same  time,  with  the  other  hand,  he  gently  pinches  the 
neck  of  the  tumour,  so  as  to  enable  it  to  enter  more  easily.  The 
surgeon  should  ascertain  whether  he  is  dealing  with  an  inguinal 
or  a  femoral  rupture,  for  the  direction  in  which  pressure  should 
be  made  differs  somewhat  in  each  case.  The  taxis  should  be 
employed  carefully ;  much  harm  is  often  done  by  its  prolonged 
and  injudicious  use. 

If  manipulation  fails,  the  patient  may  be  brought  thoroughly 
under  the  influence  of  chloroform  ;  or  he  may  be  placed  in  a 
warm  bath  ;  or  a  full  dose  of  opium  may  be  given — and  the  taxis 
tried  again.  Or  a  bladder  of  ice  may  be  applied  to  the  tumour 
for  a  couple  of  hours  ;  or  the  patient  may  be  inverted — that  is  to 
say,  the  lower  part  of  his  body  raised  on  pillows,  so  as  to  empty  the 
sac  of  some  of  its  fluid  contents — and  then  the  taxis  may  be  used 
as  before.  Purgatives  should  not  be  given,  but  the  lower  bowel 
may  with  advantage  be  cleared  out  by  a  simple  enema.  Other 
remedies,  such  as  venesection,  antimony,  tobacco,  &c.,  used  to  be 
in  vogue ;  but  if  those  which  we  have  enumerated  above  are 
fully  and  fairly  tried  without  producing  any  effect,  the  sooner  an 
operation  is  performed  the  better.    Delay  adds  much  to  the  danger. 

Operation  for  strangulated  hernia. — A  fold  of  skin  over  the 


HERNIA.  293 

neck  of  the  tumour  should  be  raised,  transfixed,  and  the  knife 
made  to  cut  its  way  out.  The  coverings  are  then  divided  by  a 
careful  dissection,  layer  by  layer,  until  the  sac  is  reached.  This 
may  be  known  by  its  glistening,  silvery  appearance,  and  by  the 
branching  vessels  on  its  surface. 

The  question  now  arises.  Should  the  sac  be  opened  or  not  ?  To 
this  I  reply  that,  as  a  general  rule,  the  sac  ought  always  to  be 
opened.  Unless  we  open  the  sac  we  cannot  tell  what  is  the  con- 
dition of  the  intestine,  nor  can  we  be  sure  that  there  is  not  a 
second  constriction  within  the  sac.  Such  an  opening  need  not  be 
extensive.  In  many  cases  it  is  enough  if  it  will  admit  the  fore- 
finger, so  as  to  enable  us  to  explore  the  cavity. 

The  point  of  constriction  is  generally  found  to  be  either  the 
thickened  neck  of  the  sac  or  some  tendinous  or  membranous  band 
outside  it. 

Fig.  127  represents  a  portion  of  the  ileum,  of  which  a  knuckle 


Fiff.  127. 


Strangulated  hernia, 

had  been  strangulated  in  the  crural  ring.  The  patient  was  a 
middle-aged  woman.  The  constriction  was  remarkably  tight, 
and  had  existed  for  sixty  hours  before  it  was  released.  The 
patient  died  on  the  fourth  day  after  the  operation.  The  knuckle 
was  gangrenous,  and  there  was  considerable  peritonitis. 

In  operating  for  a  strangulated  oblique  inguinal  hernia,  the 
constriction  will  sometimes  be  found  at  the  external,  but  more 
frequently  at  the  internal,  abdominal  ring.  It  should  be  divided 
on  the  finger,  or  on  a  director,  with  the  hernia-knife.  The  in- 
cision should  be  made  directly  upwards — that  is  to  say,  parallel 
to,  and  not  across,  the  course  of  the  epigastric  vessels. 

In  the  ease  of  a  strangulated  femoral  hernia,  the  constriction 
will  be  found  either  at  the  inner  part  of  the  falciform  process  of 
the  fascia  lata,  or  else  at  Gimbernat's  ligament.  In  either  case 
the  edge  of  the  knife  should  be  directed  ujpioards  and  inwards. 
A  mere  nick  often  suffices  to  relieve  the  constriction. 


294 


DISEASES   OF  TISSUES  AND   OEGANS. 


It  should  be  borne  in  mind  that  the  obturator  artery  sometimes 
arises  from  the  epigastric.  When  it  does  so,  it  hes  close  to  the 
falciform  border  of  Gimbernat's  ligament,  and  would  thus  em- 
brace the  neck  of  a  femoral  hernia.  The  operator  should 
therefore  proceed  with  caution. 

If  the  gut  is  merely  congested,  of  a  ruby  or  claret  colour,  but 
smooth  on  its  surface,  and  firm  in  its  texture,  it  should  be  re- 
turned without  hesitation ;  but  if  it  is  rough,  friable,  patchy,  of  a 
black,  gvey,  or  greenish  colour,  it  should  be  drawn  gently  out, 
the  gangrenous  portion  cut  off,  the  edges  of  the  wound  stitched  to 
the  integuments,  and  the  case  treated  as  one  of  artificial  anus. 

If  the  omentum  is  mortified,  the  gangrenous  portion  should  be 
cut  off,  and  the  bleeding  vessels  secured  by  torsion,  or  by  a  fine 
ligature.  It  may  then  be  left  protruding  through  the  aperture, 
in  the  hope  that  it  may  become  adherent,  and  close  the  opening. 
After  the  operation  the  edges  of  the  wound  should  be  brought 
together  and  secured  by  sutures.  A  little  water-dressing  should 
be  applied,  covered  by  a  pad  and  a  bandage.  The  diet  should  be 
bland  but  nutritious.  If  need  be,  a  simple  enema  may  be  given, 
but  purgatives  ought  to  be  avoided ;  the  bowel  sho\ild  have  a  few 
days'  rest  in  order  to  enable  it  to  recover  itself. 

If  the  symptoms  of  strangu- 
-t  ig.  128.  lation    exist,  while  the  precise 

nature  of  the  tumour  is  doubt- 
ful, the  general  rule  is  to 
operate. 

Umbilical  hernia  often  occurs 
in    infants.       Sometimes   it    is 
congenital,     but     much     more 
frequently  it  manifests  itself  a 
few  days  after  birth  ;  the  crying 
or  straining  of  the  child  causing 
a  portion  of   the  intestines  to 
protrude  at  the  umbilical  aper- 
ture.     Occasionally   this   form 
of  rupture    is  seen  in   adults, 
and   then   it   is  probable   that 
there  has  been  some  ulceration 
round  the  navel  in  infancy,  or 
some  other  cause  of  weakness. 
Fig.  128  represents  a  large 
irreducible  umbilical  hernia   in   an  old  woman,  aged  seventy- 
one.     It  had  existed  about  three  years.     She  attributed  it  to 
over-exertion  in  nursing  a  relative — a  tall,  heavy  man. 

Treatment. — If  tho  hernia  cannot  be  reduced,  a  truss,  with  a 


Irreducible  umbilical  hernia. 


HERNIA. 


295 


hollow  pad  adapted  to  the  tumour,  should  he  hahitually  worn. 
If  it  becomes  strangulated,  an  operation  must  he  undertaken 
of  the  same  nature,  and  with  the  same  object,  as  that  which  we 
have  described  in  speaking  of  inguinal  hernia ;  but  adapted,  of 
course,  to  the  anatomy  of  the  part. 

Usually,  however,  there  is  no  difficulty  in  returning  an  umbilical 
hernia.  By  a  little  manipulation  the  protruded  intestine  can  be 
restored  to  its  place,  and  then  the  patient  must  wear  a  truss  to 
prevent  it  from  protruding  again.  The  simplest  sort  of  truss 
consists  of  an  elastic  band  passing  round  the  patient's  body,  and 
pressing  upon  a  pad,  which  is  placed  over  the  aperture  by  which 
the  hernia  escapes.  Very  convenient  appliances  of  this  descrip- 
tion may  be  obtained  from  the  surgical  instrument  makers.  In 
hospital  practice  it  often  suffices  to  apply  a  pad  over  the  umbilical 
opening,  and  to  fix  it  by  means  of  a  strip  of  adhesive  plaster.  A 
suitable  pad  for  these  cases  may  be  made  by  taking  a  flat  cork,  or 
a  small  piece  of  wood,  and  folding  it  in  lint.  With  these  simple 
materials  a  truss  may  be  made  vvhich  answers  all  practical  pur- 
poses ;  and,  as  the  subjects  of  this  complaint  are  generally  infants, 
the  adhesive  plaster  has  the  advantage  of  not  being  easily  dis- 
placed by  the  movements  of  the  little  patient. 

If  these   measures  are   adopted,  Nature  seldom  fails  to  do 
the   rest.       Hence  it   is   that  in   rural 
districts    many     superstitious    practices 
receive  the  credit  of  effecting  a  cure. 

In  cases  of  umbilical  hernia  the  truss 
should   be    worn    constantly — being  re- 
newed from   time   to   time   as   circum- 
stances  may   require;    and  care  should 
be   taken   that    it    is    always    properly 
adjusted,    and    that   it    presses   with    a 
slight,  but  even,  force  upon  the  aper- 
ture   over    which   it    is    placed,    so    that    the    bowel    cannot 
escape  behind  it.     Mr.  Wood  is  of  opinion  that  the  pressure 
ought  not  to  be  exerted  upon 
the   centre   of  the   aperture, 
but  upon  its  margins  ;  for  if 
the  pressure  is  central  it  tends 
to      enlarge      the     aperture, 
whereas  if  it  is  marginal  it 
has  the  opposite  effect.    With 
this   view   he   has   devised  a 
pad  for  umbilical  hernia  (Fig. 
129)  made  of  india-rubber  or 
gutta-percha,  and  which  con- 


Pig.  129. 


Pad  for  umbilical 
hernia. 


Fi^.  130. 


296 


DISEASES   OF  TISSUES  AND  ORaANS. 


sists  of  a  thin,  flat  base  lying  in  contact  with  the  skin,  and  an 
oval  ridge  which  corresponds  to  the  margins  of  the  hernial  aper- 
ture, and  upon  which  the  pressure  is  exerted  by  means  of  an 
elastic  belt.  The  accompanying  diagram  (Pig.  130), copied  from  Mr. 
Wood's  treatise  on  Rupture,  is  intended  to  represent  a  sectional 
view  of  the  abdominal  walls  in  a  case  of  umbilical  hernia ;  and  to 
show  the  direction  in  which  the  pressure  is  exerted  by  such  a 
contrivance  as  we  bave  described. 

IMPERFORATE  JLNVS. 

Sometimes  there  is  a  congenital  deficiency  of  the  anus  :  there 
is  no  free  passage  between  tbe  bowels  and  the  anus.  This  mal- 
formation is  more  common  in  male  than  in  female  children. 

In  these  cases  the  rectum  may  terminate  in  the  bladder  j  or 
it  may  take  its  proper  course,  but  fail  to  reach  the  anus  by  an 
inch  or  more;  or  the  rectum  may  be  complete,  but  the  anus 
closed  by  a  membrane.  These  are  the  commonest  varieties  of  the 
malformation.     Fig.  131  represents  the  first  variety.     It  was 


Fig.  131. 


Fig.  132. 


Imperforate  anus  (1). 


Imperforate  anus  (2). 


drawn  from  a  case  of  Mr.  Spencer  Watson's.  Fig.  132,  showing 
the  second  variety,  occurred  in  my  own  practice. 

Treatment. — If  the  anus  is  merely  skinned  over,  and  the 
membrane  distended  by  an  accumulation  of  meconium,  an  incision 
should  be  made  at  once. 

If,  however,  the  aperture  is  firmly  closed,  a  sharp-pointed 
trochar  and  canula  of  sufficient  size,  or  a  curved  bistoury,  should 
be  introduced  very  carefully  upwards  and  backwards,  to  the 
extent  of  an  inch.  The  surgeon  should  then  explore  the  wound 
with  his  finger,  in  the  hope  of  reaching  the  gut.     If  he  succeeds. 


HAEMORRHOIDS.  297 

he  should  draw  it  down,  and  stitch  it  to  the  edges  of  the  super- 
ficial wound.  If  he  fails,  the  only  remedy  is  to  perform  Amus- 
sat's  operation,  and  make  an  artificial  anus  in  the  left  lumbar 
region. 

FISSURB  OF  THE  ASJUS. 

The  mucous  membrane  at  the  verge  of  the  anus  is  apt  to  be- 
come cracked  or  fissured.  When  this  happens,  there  is  exquisite 
pain,  the  sphincter  is  spasmodically  contracted,  and  the  nates  are 
pressed  together,  so  that  it  is  extremely  diflScult  to  get  a  clear 
view  of  the  disease.  The  pain  is  so  much  aggravated  by  defeca- 
tion that  the  patient  dreads  going  to  stool.  The  general  health 
suffers,  and  the  invalid  becomes  pale,  thin,  and  anxious-looking. 

The  fissure  is  generally  associated  with  a  disordered  state  of 
the  stomach.  Sometimes  it  appears  to  depend  upon  syphilis.  It 
is  often  found  lying  at  the  base  of  an  external  pile,  or  tag  of 
hypertrophied  skin. 

Treatment. — The  bowels  should  be  regulated,  so  that  the 
motions  shall  always  be  soft  and  semi-fluid.  The  fissure  should 
be  touched  with  bluestone,  or  with  a  pencil  of  lunar  caustic.  If 
this  fails,  an  incision  should  be  made  through  the  fissure,  so  as  to 
divide  the  mucous  membrane  and  a  few  of  the  fibres  of  the 
sphincter.  This  clean-cut  wound  soon  heals  from  the  bottom,  in 
the  ordinary  way. 

UIiCER  OF  THE  RECTVXWE 

often  results  from  an  aggravated  fissure.  Sometimes  it  is 
situated  upon  the  verge  of  the  anus ;  sometimes  it  is  within  the 
sphincter.  The  surgeon  must  search  for  it  carefully  both  with 
his  finger  and  also  with  the  small  speculum  that  is  made  for  the 
purpose. 

It  gives  rise  to  much  the  same  symptoms  as  fissure  of  the  anus, 
and  the  treatment  must  be  conducted  on  the  same  general  prin- 
ciples. When  it  is  situated  at  the  verge  of  the  anus,  it  should 
be  divided,  and  the  incision  carried  through  the  sphincter. 
When  it  is  internal  to  the  muscle,  it  may  sometimes  be  cured  by 
the  local  use  of  the  nitrate  of  silver,  while  the  bowels  are  care- 
fully regulated,  and  the  pain  and  irritation  are  allayed  by  small 
anodyne  injections  or  suppositories  (F.  90).  If  the  case  is  of  long 
standing,  it  may  be  necessary  here  also  to  divide  the  sphincter. 

H2:iVXORRHOIDS 

(piles)  is  the  name  given  to  certain  tumours,  which  are  apt 
to  form  at,  or  near,  the  anus.  They  consist  essentially  of  a 
dilated,  varicose,  and  hypertrophied  condition  of  the  veins  at  the 
lower  part  of  the  rectum. 


298  DISEASES   OF  TISSUES  AND  OEGANS. 

Whatever  favours  the  accumulation  of  blood  in  the  lower 
bowel  predisposes  to  piles ;  for  example,  constipation,  disease  of 
the  liver,  pregnancy,  &c.  The  upper  classes,  from  their  luxurious 
habits  and  the  sedentary  nature  of  their  employments,  are  more 
apt  to  have  hsemovrhoids  than  the  lower.  Whatever  irritates  or 
inflames  the  rectum,  excites  to  "a  fit  of  the  piles;"  for  example, 
diarrhoea,  cold  and  wet,  &c. 

Haemorrhoids  are  divided  into  those  which  are  external  to  the 
sphincter,  and  those  which  are  internal. 

External  piles  form  small  tumours,  at  the  verge  of  the  anus, 
of  a  purple  or  bluish  colour,  covered  partly  by  thickened  mucous 
membrane,  partly  by  hypertrophied  skin.  As  a  rule,  they  do  not 
bleed.  When  they  are  irritated  and  congested,  as  they  frequently 
are  towards  evening,  they  give  rise  to  intolerable  itching  and 
smarting.  When  they  become  acutely  inflamed,  they  form  hard, 
tense,  purple  tumours,  which  are  exquisitely  painful. 

Treatment. — If  external  piles  are  cut  off  with  scissors,  and 
the  sores  allowed  to  heal,  a  radical  cure  is  effected.  They  may, 
however,  be  palliated  and  kept  in  check  by  carefully  regulating 
the  diet  and  bowels.  The  evacuations  should  always  be  soft  and 
pasty.  To  this  end,  a  mild  laxative — a  little  of  the  confection 
of  senna,  for  example — should  be  taken  every  night.  At  the 
same  time,  soothing  or  astringent  ointments — e.g.,  cacao  butter 
or  the  ung.  gallse  co. — should  be  applied  locally.  Sponging  the 
part  with  cold  water  every  morning,  and  also  after  the  bowels 
have  been  moved,  is  of  the  utmost  benefit. 

When  an  external  pile  is  acutely  inflamed,  fomentations  should 
be  used.  Or  a  free  incision  should  be  made  through  it,  when 
small  coagula  of  blood  will  escape.  This  will  give  immediate 
relief,  and  ultimately  effect  a  cure. 

Internal  piles  are  situated  within  the  sphincter  ani.  Some- 
times they  form  pendulous  tumours ;  sometimes  they  are  attached 
by  a  broad  base.  They  may  habitually  protrude  from  the  anus, 
or  they  may  descend  only  when  the  bowels  are  moved.  They  bleed 
freely,  and  often  give  rise  to  general  angemia.  They  are  apt  to 
become  inflamed,  and  when  this  happens  the  symptoms  run  high. 
There  is  great  pain  and  irritation,  not  only  in  the  rectum,  but 
in  the  genito-urinary  organs  as  well. 

The  general  treatment  is  the  same  as  for  external  piles.  We 
must  regulate  the  diet,  and  study  the  state  of  the  bowels  and 
liver.  The  bleeding  may  be  checked  by  astringents,  either  given 
internally — e.g.,  gallic  acid  or  the  muriated  tincture  of  iron, 
— or  as  injections — e.g.,  alum,  tannin,  &c.  (F.  15,  17).  Here, 
too,  the  cold  bath  is  of  great  service.  It  should  be  borne  in 
mind  that,  in  the  case  of  plethoric  persons,  it  is  not  always  safe 


PEOLAPSUS  RECTI.  299 

to  stop  the  discharge  of  blood.     If  inflammation  occurs,  fomen- 
tations and  saline  purgatives  will  give  the  greatest  relief. 

In  order  to  eflect  a  radical  cure  of  internal  piles,  they  must 
be  removed  by  an  operation.  The  patient  should  sit  over  a  pan 
of  warm  water,  and  then  strain,  so  as  to  bring  the  tumours  fully 
into  view.  They  may  then  be  strangulated,  either  with  a  single 
loop  of  twine,  or  by  passing  a  double  ligature  through  the  base  of 
the  pile,  and  tying  each  half  separately.  In  some  cases  the 
ecraseur  may  be  used ;  in  others  they  may  be  grasped  with  a 
suitable  clamp,  cut  off,  and  the  edges  of  the  wound  touched  with 
nitric  acid,  or  with  the  actual  cautery.     The  most  convenient 

Fig.  133. 


Mr.  H.  Smith's  clamp  for  hEemorrhoids. 


clamp  for  this  purpose  is  that  which  has  been  devised  by    Mr. 
Henry  Smith  (Fig.  133). 

PROIiAPSUS  RECTI. 

The  raucous  lining  of  the  rectum  sometimes  protrudes  beyond 
the  anus,  forming  prolapsus  recti  (Fig.  134).  Whatever  irri- 
tates, relaxes,  and  stretches  the  mucous  membrane  may  lead 
to  this  complaint — for  example,  internal  piles,  thread-worms, 
stone  in  the  bladder,  constipation,  with  habitual  straining  at 
stool.  It  is  often  met  with  in  young  children,  especially  in  con- 
nection with  such  sources  of  irritation  as  have  just  been  mentioned. 

A  tumour  of  varying  size  presents  itself  at  the  anus.  At  first 
it  is  bright  red,  like  healthy  mucous  membrane;  but  if  it  comes 
down  often,  it  gradually  becomes  thickened  and  callous,  and  more 
like  the  skin. 

The  treatment  consists  in  removing  the  cause,  as  in  the  case  of 
ascarides,  stone  in  the  bladder,  &c.,  in  regulating  the  bowels,  so 
that  the  fseces  shall  always  be  soft  and  semi-fluid,  and  in  giving 
tone  and  vigour  to  the  system.  If  possible,  the  patient  should 
pass  his  motions  in  the  recumbent  position.     AVhen  the  bowel 


300 


DISEASES  OF  TISSUES  AND  ORGANS. 


Fio;.  134. 


surgeons    speak 
applying  nitric 


descends,  it  should  be  carefully  and  gently  replaced.  The  parts 
should  be  frequently  sponged  with  cold  water,  or  with  an 
astringent  lotion.  Injections  of  an 
astringent  character  should  be  introduced 
into  the  rectum — e.g.,  a  grain  or  two 
of  sulphate  of  iron  in  an  ounce  of  water. 

If  an  operation  becomes  necessary,  the 
ligature  should  be  used ;  as  in  the  case 
of  internal  piles — our  object  being  to 
remove  some  of  the  superfluous  folds  of 
mucous  membrane,  and  to  contract  the 
anal  aperture.  Some 
highly  of  the  effect  of 
acid. 

Sometimes  a   pessary,  or   a   pad    and 
bandage,  may  be  worn  with  advantage. 

"^ -Handage  for  the  Perineum. — The 
simplest  appliance  of  this  kind  is  made 
by  passing  a  single  turn  of  bandage  round 
the  patient's  waist,  tying  it  behind,  and  then  carrying  the  roller 
under  the  perineum,  and  fastening  it  to  the  waistband  in  front. 
Or  the  surgeon  may  prefer  a  compound  bandage  made  by  sewing 
together  two  pieces  of  cotton  roller,  or 
other  material,  at  a  right  angle  to  one 
'  another  (Fig.  135).  First  of  all,  a  piece 
of  broad  bandage  is  taken  of  suffi- 
cient length  to  pass  round  the  waist  and 
fasten  in  front.  To  the  centre  of  this  is 
stitched  at  right  angles  another  strip  of 
bandage,  long  enough  to  be  brought  under 
the  perineum  and  attached  in  front  to  the 
waistband.  It  is  important  that  this  should 
be  stitched  across  the  whole  width  of  the 
waistband,  so  as  to  give  it  a  firm  attach- 
ment, for  it  is  upon  this  point  that  the 
Sometimes  the  perineal  band  is  left  entire  j 


Prolapsus  recti. 


Fig.  135. 


T-bandage. 


traction  is  made, 
sometimes  it  is  torn  down  the  centre,  so  as  to  make  two  tails, 
and  these  are  brought  up,  one  on  each  side  of  the  scrotum,  and 
attached  to  the  waistband  in  front.  The  exact  way  in  which  the 
bandage  is  adjusted  depends  upon  the  purpose  for  which  it  is 
applied,  and  the  surgeon  must  use  his  own  judgment  in  the 
matter.  It  is  very  useful  for  supporting  the  perineum  in  cases 
of  prolapsus  of  the  rectum  or  of  the  uterus,  for  retaining  pessa- 
ries, for  fixing  dressings  about  the  anus,  &c.  As  a  general  rule, 
in  applying   dressings  to  the  anus,  the    bandage  ought  to  be 


FISTULA   IN  ANO.  301 

brought  from  behind  forwards,  in  the  way  we  have  de- 
scribed. 

FisTUZiA  irr  Alio 

is  the  name  given  to  sinuses  or  fistulous  tracks,  which  are  apt  to 
form  in  the  neighbourhood  of  the  rectum,  between  it  and  the  skin 
around  the  anus.  The  fistula  may  communicate  with  a  free  sur- 
face at  both  ends,  or  only  at  one.  When  it  is  open  at  both  ends, 
it  is  said  to  be  complete.  If  it  communicates  with  the  bowel 
alone,  it  is  called  a  hlind  internal  fistula ;  if  with  the  skin  alone, 
it  is  termed  a  blind  external  fistula. 

The  disease  seems  sometimes  to  begin  in  ulceration  of  the 
mucous  membrane  of  the  bowel.  Perhaps,  in  consequence  of  the 
lodgment  of  foreign  bodies,  or  minute  masses  of  hardened  fiDeces, 
an  abscess  forms,  which  burrows  and  makes  its  way  in  various 
directions  by  the  side  of  the  rectum.  At  other  times,  it  appears 
to  originate  in  spontaneous  inflammation  of  the  cellular  tissue  in 
the  ischio-rectal  fossa,  running  on  to  suppuration,  and  extending 
either  outwards  towards  the  skin,  or  inwards  towards  the  gut. 

Fistula  in  ano  is  often  associated  with  phthisis,  and  in  such 
instances  it  depends,  no  doubt,  upon  the  tendency  there  is  in  that 
disease  to  ulceration  of  the  intestines. 

The  symptoms  of  fistula  are  those  of  acute  local  inflammation, 
running  on  to  suppuration.  At  first,  there  is  pain,  heat,  tension, 
with  disorder  of  the  general  health ;  then  there  is  commonly  the 
discharge  of  purulent  matter,  mixed  with  fseces  and  flatus.  The 
symptoms  vary  of  course  somewhat,  according  to  the  precise 
nature  of  the  case. 

A  fistula  shows  no  natural  tendency  to  heal;  partly,  because 
irritating  matters  from  the  bowels  are  constantly  filtering  through 
it,  but  chiefly,  because  its  sides  are  in  frequent  motion  by  the 
action  of  the  levator  and  sphincter  ani  muscles. 

In  order  to  ascertain  the  extent  of  a  fistula,  one  finger  should 
be  introduced  into  the  rectum,  while  a  probe  is  passed  upwards 
through  the  fistulous  track.  If  the  case  is  one  of  blind  internal 
fistula,  there  will  generally  be  found  an  abscess,  pointing  some- 
where near  the  anus.  This  should  be  opened,  and  then  the  case 
becomes  one  of  complete  fistula. 

The  only  treatment  worthy  of  notice  is  by  operation,  and  this 
is  so  simple  and  so  efiicieut  that  it  is  almost  universally  prac- 
tised. In  a  case  of  complete  fistula,  the  surgeon  introduces  his 
left  forefinger  into  the  rectum;  while,  with  his  right  hand,  he 
passes  a  blunt-pointed,  curved  bistoury  along  the  fistulous  track 
through  the  opening  in  the  bowel,  and  presses  it  firmly  against 
the  point  of  his  finger.     He  then  withdraws  his  finger  and  the 


302  DISEASES   OF  TISSUES  AND  OEQANS. 

knife  together,  so  as  to  cut  through  everything  between  the  sinus 
and  the  anus.  Thus  the  fistuhi  is  laid  freely  open,  and  the 
sphincter  divided.  Another  and  more  convenient  plan  is  to  pass 
a  director  in  at  the  fistulous  opening,  and  to  bring  it  out  at  the 
anus.  This  may  easily  be  done  by  a  little  manipulation.  The 
intervening  tissues  must  then  be  divided  by  running  a  knife 
along  the  groove.  If  there  are  several  sinuses,  a  director  should 
be  introduced  into  each  before  the  knife  is  applied  to  any.  The 
wound  should  be  filled  with  a  strip  of  oiled  lint,  so  as  to  insure 
its  healing  from  the  bottom.  Blind  fistulse  should  be  converted 
into  complete  ones,  and  then  treated  as  above. 

After  the  operation,  opium  should  be  given  freely  to  keep  the 
bowels  quiet.  On  the  third  morning  a  dose  of  castor  oil  should 
be  administered.  This  will  bring  away  the  first  dressings.  The 
wound  should  then  be  dressed  every  day  with  oiled  lint,  carefully 
introduced  by  means  of  a  probe,  so  as  to  prevent  superficial  healing. 

In  cases  where  fistula  is  associated  with  phthisis — especially 
if  the  lungs  are  much  affected — it  becomes  a  nice  question  whether 
an  operation  should  be  performed  or  not. 

STRICTURE  OF  THE  RECTUM 

may  be  either  spasmodic  or  permanent. 

Spasmodic  stricture  of  tJie  rectum  is  rare.  It  depends,  either 
upon  dei-angement  of  the  general  health,  or  on  the  presence  of 
an  ulcer  or  fissure. 

Permanent  stricture  of  the  rectum  is  more  commonly  met  with, 
and  may  be  either  simple,  syphilitic,  or  malignant. 

Simple  stricture  is  usually  the  result  of  chronic  inflammation 
of  the  rectum,  with  thickening  of  the  lining  membrane,  and 
deposit  of  lymph  in  the  submucous  areolar  tissue.  The  stricture 
is  generally  situated  within  reach  of  the  finger,  two  or  three 
inches  from  the  anus. 

Symptoms. — There  is  a  difficulty  in  passing  the  motions.  The 
fajces  are  sometimes  flattened  into  ribbons;  in  other  cases,  they 
are  formed  into  small,  hard,  round  masses.  The  bowel  above 
the  seat  of  obstruction  becomes  distended,  and  is  very  apt  to 
ulcerate.  Tl)e  genito-urinary  organs  become  sympathetically 
affected,  and  the  general  health  suffers. 

The  treatment  consists  in  passing  bougies,  until  a  full-sized 
instrument  can  be  introduced  without  difficulty.  Even  then,  the 
patient  should  be  warned  that  the  disease  will  assm-edly  return 
unless  a  bougie  is  passed  occasionally. 

Syphilitic  stricture  must  be  treated  by  the  same  mechanical 
means,  and  by  the  prescription  of  anti- syphilitic  remedies  (F.  49, 
50,  60). 


RETENTION  OF  UEINE.  303 

Malignant  stricture  may  be  considered  along  with  cancer  of 
the  rectum. 

CANCER  OF  THS  RECTUXVI 

is  generally  of  the  epithelial,  but  sometimes  of  the  scirrhous  or 
of  the  medullary  kind.  It  is  often  associated  with  piles,  or  with 
simple  stricture ;  for  here,  as  elsewhere,  cancer  is  apt  to  attack 
tissues  which  are  not  in  a  natural  state.  It  is  usually  situated 
at  the  lower  part  of  the  rectum,  so  that  it  can  be  felt  with  the 
tinger. 

Si/mptoms. — In  addition  to  the  ordinary  symptoms  of  stricture 
of  the  bowel,  there  is  impairment  of  the  general  health,  pain 
darting  through  the  back  and  thighs,  and  the  discharge  of  offen- 
sive, bloody,  purulent  matter.  The  inability  to  control  the  anal 
orifice  and  the  involuntary  discharge  of  feculent  matter  add 
much  to  the  patient's  distress.  As  the  disease  advances,  the 
symptoms  become  more  severe,  and  the  obstruction  of  the  bowels 
is  complete.     Death  generally  takes  place  from  exhaustion. 

Treatment. — The  bowels  should  be  relieved  by  enemata,  or  by 
small  doses  of  castor  oil.  Wiien  the  necessity  arises,  a  bougie 
should  be  passed,  to  keep  the  passage  open.  Pain  should  be 
allayed  by  opium  or  other  sedatives,  given  either  by  the  mouth 
or  in  the  form  of  a  suppository.  Marine  tow  makes  an  excellent 
local  application.  If  the  disease  is  limited,  the  lower  part  of  the 
rectum,  to  the  extent  of  three  or  four  inches,  may  be  excised. 
As  a  last  resource,  to  relieve  the  patient's  distress  and  to  prolong 
his  life,  colotomy  may  be  performed. 

RETENTXOia-  OF  URISCTS 

signifies  an  inability  to  discharge  the  urine,  and  must  not  be  con- 
founded with  suppression,  wherein  no  urine  is  secreted. 

Retention  may  arise  from  various  causes.  They  may,  how- 
ever, all  be  classed  under  two  heads :  (1)  a  want  of  power  in  the 
bladder  to  expel  its  contents,  or  (2)  an  obstruction  to  the  passage 
of  the  urine. 

"When  the  retention  arises  from  a  want  of  power  in  the  bladder 
to  expel  its  contents,  it  is  generally  due  to  lesion  of  the  spinal 
cord  attended  by  paralysis.  In  such  a  case  there  are  no  urgent 
symptoms.  The  urine  collects  in  the  bladder,  overflows,  and 
dribbles  away  by  the  urethra :  it  soon  becomes  offensive,  am- 
moniacal,  and  loaded  with  ropy  mucus. 

The  surgical  treatment  of  these  cases  consists  in  drawing  off"  the 
water  two  or  three  times  a  day,  and  washing  out  the  bladder  by 
means  of  a  double-current  catheter.  The  medical  treatment 
must  be  regulated  according  to  the  precise  nervous  symptoms. 


304  DISEASES  OF  TISSUES  AND  OEGANS. 

Symptoms  of  retention  from  obstruction. — Urgent  desire  to 
pass  water  with  an  inability  to  do  so,  straining,  pain,  with  general 
anxiety  and  distress.  The  bladder  may  be  felt  rising  above  the 
pubes,  forming  an  elastic,  fluctuating  tumour,  which  is  dull  on 
percussion.  If  the  retention  is  not  relieved,  the  ureters  gradually 
become  dilated,  tlie  kidneys  affected  with  diffuse  pyelitis,  and 
there  is  suppression  of  urine,  followed  by  coma  and  death.  But 
it  more  frequently  happens  that  the  urethra  gives  way  behind 
the  point  of  obstruction,  and  the  urine  escapes  into  the  surround- 
ing tissues  (extravasation  ofurine^. 

When  retention  depends  upon  obstruction  to  the  passage  of 
the  urine,  it  is  generally  associated  with  stricture  of  the  urethra, 
or  enlargement  of  the  prostate.  Each  of  these  subjects  will  be 
considered  separately. 

STRICTURE  OF  THE  URETHRA 

may  be  either  spasmodic  and  temporary,  or  organic  and  per- 
manent. 

Some  surgeons  speak  of  congestive  strictures,  but  congestion 
may  supervene  either  upon  a  spasmodic  or  upon  an  organic 
stricture.  It  is,  therefore,  more  correct  to  speak  of  a  spasmodic 
stricture,  or  of  an  organic  stricture,  in  a  state  of  congestion,  than 
to  speak  of  a  congestive  stricture. 

Spasmodic  stricture  is  caused  by  contraction  of  the  muscles 
which  surround  the  membranous  portion  of  the  urethra,  or  of 
the  unstriped  muscular  fibre,  which  forms  part  of  the  walls  of 
the  canal. 

The  predisposing  causes  are  an  organic  stricture,  gleet,  piles, 
or  other  sources  of  irritation  about  the  urethra  or  rectum ;  and,  in 
women,  the  hysterical  temperament.  The  exciting  causes  are 
usually  exposure  to  cold  and  wet,  or  excessive  and  unwonted 
indulgence  in  drink. 

Treatment. — In  all  cases  of  stricture  the  medical  treatment 
ought  on  no  account  to  be  overlooked.  Rest  in  bed,  warmth,  an 
active  aperient,  and  sedatives  will  often  do  much  to  relieve  the 
patient. 

In  the  case  of  a  spasmodic  stricture,  fomentations,  a  warm 
bath,  a  full  dose  of  opium,  or  an  opiate  suppository  (F.  90) — these 
means  will  often  enable  the  patient  to  empty  his  bladder.  If  they 
fail  to  remove  the  spasm,  chloroform  should  be  given,  and  the  sur- 
geon should  introduce  a  large  catheter  (No.  8  or  9).  If  the 
distension  is  already  great,  this  method  should  be  adopted  at 
once.  When  the  present  attack  has  been  overcome,  the  patient's 
general  health  should  be  regulated  ;  and  he  should  be  warned  of 
those  conditions  which  are  apt  to  excite  spasm. 


STRICTURE   OF  THE  URETHRA. 


305 


Fig.  136. 


Organic  stricture  is  the  result  of  inflammation  in  or  near  the 
urethral  canal.  Such  inflammation  is  very  often  gonorrhoeal, 
but  it  may  also  be  excited  by  external  injury,  or  by  the  use  of 
too  strong  an  injection.  In  any  of  these  cases,  a  stricture  may 
be  formed  by  the  eff"usion  of  lymph  into  the  lining  membrane  of 
the  urethra,  or  into  the  submucous  areolar  tissue.  A  stricture 
may  also  result  from  the  cicatrization  of  an  ulcer,  simple  or  spe- 
cific. In  this  way,  chancres  near  the  orifice  often  give  rise  to 
troublesome  strictures. 

The  character  of  the  stricture  may  vary  :  sometimes  it  is 
annular,  as  if  a  thread  had  been  tied  round  the  urethra ;  some- 
times it  is  long ;  sometimes  it  is  situated  on  one  side  only  of  the 
canal  J  sometimes  it  is  rough  and  cartilaginous;  sometimes  a  fold, 
like  a  valve,  is  thrown  across  the  canal  j  sometimes  a  band,  like  a 
bridle. 

The  most  common  seat  of  stricture  is  at  the  junction  of  the 
membranous  with  the  spongy  portion  of  the  urethra,  or  a  little 
in  front  of  this  point.  Fig.  136  was 
drawn  from  a  specimen  in  the  museum 
of  Charing  Cross  Hospital,  and  repre- 
sents a  stricture  of  the  urethra  asso- 
ciated with  an  abscess  in  the  prostate. 

When  a  stricture  has  once  formed, 
it  tends  to  become  worse;  the  con- 
traction goes  on  increasing ;  the 
urethra  behind  the  point  of  constriction 
becomes  dilated.  The  muscular  coat 
of  the  bladder  gets  thickened  and 
hypei'trophied,  and  the  lining  mem- 
brane is  disordered.  The  ureters 
become  distended  and  tortuous;  the 
kidneys  congested,  and  liable  to  acute 
inflammation.  Thus  the  stricture 
gradually  extends  its  pernicious  in- 
fluence in  a  backward  direction,  while 
the  constant  irritation  makes  the 
patient  nervous  and  depressed.  At 
first  the  constitution  may  suffer  little  or 
nothing ;  but,  ultimately,  it  is  apt  to 
become  seriously,  and  even  fatally,  affected.  If,  however,  the 
patient  takes  timely  advice,  these  evils  may  be  avoided. 

Symptoms. — The  patient  gradually  finds  that  he  has  more 
frequent  calls  to  make  water.  The  eflrort  to  do  so  is  attended 
with  pain  and  diflBculty.  The  stream  is  diminished,  forked,  or 
scattered.     In  very  bad  cases  the  urine  is  passed  drop  by  drop, 


Stricture  of  the 
urethra. 


306  DISEASES  OF  TISSUES  AND   OKGANS. 

and  with  mucb  straining.  The  act  of  micturition  may  be  fol- 
lowed by  rigors  or  prostration.  There  is  often  a  continuous 
gleety  discharge  from  the  urethra,  or  intercurrent  attacks  of 
orchitis,  or  other  indications  of  local  irritation.  The  patient  is 
liable  to  occasional  fits  of  retention,  which  are  associated  with 
more  or  less  inflammation  at  the  seat  of  stricture. 

Treatment. — If  there  is  reason  to  suspect  a  stricture,  a  catheter 
of  large  size  (No.  8  or  9)  should  be  cautiously  passed  along  the 
urethra.  If  a  stricture  is  present,  an  obstruction  will  be  felt, 
and  it  will  be  necessary  to  try  smaller  instruments,  until  one  is 
found  which  can  be  introduced  into  the  bladder  without  using 
undue  force. 

With  regard  to  catheters,  the  most  manageable,  and  therefore 
the  most  generally  useful,  are  the  silver  instruments ;  and  if  they 
are  handled,  as  they  always  should  be,  with  a  light  and  elastic 
touch,  and  with  constant  regard  to  theanatomy  of  the  urethra,  the 
risk  of  injury  is  very  slight.  There  are,  however,  some  cases — for 
example,  those  of  spasmodic  stricture — in  which  a  gum-elastic 

instrument,  either  with  or 
^°'        '  without  its  stylet,  is  pre- 

ferable.    The  soft  French 
hulbous  lougie  (Fig.    137) 
Bulbous  bougie.  is  sometimes   very   useful. 

No  instrument  glides 
through  an  irritable  passage  with  less  discomfort  to  the  patient. 
While  in  other  cases,  more  particularly  if  the  stricture  is  long, 
tight,  and  twisted,  the  filiform,  or  the  catgut  bougie  is  of  great 
service. 

When  a  catheter  has  to  be  introduced,  the  patient  may  either 
stand  with  his  back  against  a  wall,  his  legs  separated,  and  his 
feet  slightly  advanced ;  or  he  may  lie  on  his  back  on  a  couch. 
If  he  stands  up,  the  operator  should  be  seated  opposite  him  ;  but 
if  he  lies  down,  the  surgeon  should  stand  on  his  left  side.  We 
will  suppose  the  patient  to  be  in  the  recumbent  position.  The 
instrument  which  is  to  be  used  should  be  well  warmed  and  oiled. 
The  surgeon  then  grasps  it  lightly,  but  firmly,  between  the  fingers 
and  thumb  of  the  right  hand,  while,  at  the  same  time,  he  raises  the 
penis  with  his  left.  The  point  of  the  catheter  is  then  inserted 
into  the  orifice  of  the  urethra,  and  the  instrument  is  passed  slowly 
but  steadily  along,  until  it  reaches  the  bulb — the  shaft,  mean- 
while, being  kept  low  down  on  the  left  groin,  parallel  with 
Poupart'a  ligament.  The  handle  should  next  be  swept  round, 
till  it  is  in  the  middle  line  of  the  body,  pointing  to  the  navel.  It 
is  then  bent  forwards  and  downwards.  By  this  movement  the 
point  of  the  catheter  is  directed  upwards  and  onwards,  enters  the 


STRICTURE  OF  THE  URETHRA.  307 

bladder,  and  the  urine  escapes.  The  discharge  of  urine  through 
the  instrument  is  the  only  certain  evidence  that  it  has  reached  the 
bladder. 

If  the  patient  is  in  the  erect  posture,  the  surgeon  holds  the 
catheter  vertically,  with  the  convexity  turned  towards  himself, 
aud  the  handle  directed  downwards.  The  point  of  the  instru- 
ment is  introduced  into  the  urethra,  and  carried  along  as  far  as 
the  bulb.  The  handle  is  then  swept  round  through  half  a  circle, 
until  it  lies  along  the  mesial  line  of  the  abdomen,  pointing  to  the 
umbilicus.  It  is  then  brought  downwards  and  forwards,  between 
the  patient's  legs. 

In  withdrawing  the  catheter,  the  surgeon  takes  hold  of  the 
handle  between  his  middle  and  forefingers,  so  that  he  may,  if  need 
be,  cover  the  outlet  with  his  thumb.  He  then  reverses  the  steps 
by  which  he  introduced  the  instrument,  so  as  to  remove  it  with 
as  little  pain  to  the  patient  as  possible. 

If  difficulty  arises  in  passing  an  instrument,  there  are  various 
little  manoeuvres  which  may  be  practised.  The  penis  may  be 
stretched  upon  the  catheter,  so  as  to  obliterate  any  folds  there 
may  be  in  the  mucous  membrane ;  or  the  fingers  of  the  left  hand 
may  be  applied  to  the  perineum,  behind  the  scrotum,  so  as  to  help 
the  instrument  in  its  onward  and  upward  course;  or  the  left 
forefinger,  well  oiled,  may  be  passed  into  the  rectum,  so  as  to 
direct  the  point.  The  instrument  should  be  carried  along  the 
upper  wall  of  the  urethra  rather  than  the  lower.  If  the  surgeon 
fails  with  a  metal  catheter,  he  may  perhaps  be  more  successful 
with  a  gum-elastic.  If  he  fails  in  the  recumbent  position,  he 
may  meet  with  less  difficulty  if  he  makes  his  patient  stand  up,  or 
if  he  puts  him  under  the  influence  of  an  anaesthetic.  The 
catheter  should  always  be  handled  lightly,  the  least  possible 
amount  of  force  being  used ;  our  aim  being  to  insinuate  the 
instrument  without  irritating  the  urethra,  causing  pain,  or  draw- 
ing blood.  This  is  one  of  the  occasions  on  which  the  young 
surgeon  should  bear  in  mind  the  oft-repeated  maxim  of  Hippo- 
crates— "  Do  good  if  you  can,  but  at  least  do  no  harm."  The 
most  serious,  and  even  fatal,  consequences  may  follow  an  injudi- 
cious or  unskilful  use  of  instruments.  It  requires  much  practice, 
as  well  as  great  tact  and  patience,  to  pass  the  catheter  skilfully ; 
and  cases  not  unfrequently  arise  which  baffle  the  most  accom- 
plished surgeons.  It  is  said  that  Civiale  once  spent  four  hours 
in  introducing  an  instrument  into  the  bladder. 

If  the  surgeon  fails  to  pass  an  instrument,  and  the  case  is  not 
urgent,  he  may  content  himself  with  regulating  the  bowels,  and 
ordering  fomentations  and  opiate  suppositories,  in  order  to  allay 
inflammation  and  spasm,  and  reduce  the  stricture  as  much  as 

X  2 


308  DISEASES  OF  TISSUES  AND  OEGANS. 

possible  (F.  90).  Then,  on  a  subsequent  occasion,  he  may  be  more 
successful.  Mr.  Nunn  holds,  and  I  think  with  good  reason,  that 
many  of  the  dense  cartilaginous  strictures  are  of  syphilitic  origin, 
and  are  benefited  by  a  course  of  anti-syphilitic  remedies. 

If  the  surgeon  fails  to  pass  an  instrument,  and  the  case  is 
urgent,  other  methods  of  treatment  must  be  adopted. 

a.  The  bladder  may  be  tapped  from  the  rectum.  To  do  this, 
the  surgeon  introduces  his  forefinger  into  the  rectum,  and  feels  the 
prostate.  He  then  carries  it  a  little  further,  and  touches  the 
distended  bladder.  On  his  finger  he  passes  the  curved  trochar 
and  canula  made  for  the  purpose,  and  by  a  sharp  thrust  he  forces 
them  into  the  bladder.  The  trochar  is  withdrawn,  and  the  canula 
left  in  the  wound.  When  the  prostate  is  much  enlarged,  this 
operation  cannot  be  employed. 

b.  Or  the  bladder  may  be  punctured  above  the  pubes,  either 
with  a  trochar  and  canula,  or  with  the  pneumatic  aspirator. 

c.  Or  the  urethra  may  be  opened  by  a  deep  incision  in  the 
perineum.  A  full-sized  catheter  is  passed  down  to  the  stricture. 
The  surgeon  then  introduces  his  finger  into  the  rectum,  and  feels 
the  point  of  the  instrument.  He  next  runs  a  knife,  with  its 
back  turned  towards  the  rectum,  deeply  into  the  middle  line  of 
the  perineum,  till  he  opens  the  urethra  behind  the  stricture,  a 
little  beyond  the  point  of  the  catheter.  As  he  withdraws  the 
knife,  he  cuts  forwards  and  upwards  so  as  to  enlarge  the  incision. 
In  doing  this  he  may,  if  he  thinks  proper,  divide  the  stricture  by 
cutting  on  to  the  point  of  the  catheter.  The  instrument  may 
then  be  carried  forwards  into  the  bladder,  and  fastened  in  that 
position  by  tapes.  In  this  way  the  retention  is  relieved,  and  the 
stricture  cured  at  the  same  time.  This  method  of  treatment  is 
particularly  applicable  to  cases  in  which  there  has  been  extrava- 
sation of  urine,  or  where  there  are  fistulous  openings  in  the 
perineum.  But  the  operation  is  often  attended  with  great  diffi- 
culty ;  indeed,  Erichsen  says  it  is  the  most  troublesome  in  surgery, 
and  the  after-risks  are  considerable. 

Another  method  of  dealing  with  the  same  class  of  cases  is  that 
which  is  called  the  "button-hole"  operation.  It  consists  in 
passing  a  large  catheter  down  to  the  stricture,  then  turning  it 
round  so  that  the  point  projects  in  the  perineum.  The  surgeon 
cuts  down  upon  this,  and  thus  opens  the  urethra  just  in  front  of  the 
stricture.  The  catheter  is  next  withdrawn,  and  the  edges  of  the 
urethral  wound  are  seized  and  drawn  forwards.  A  probe  is  passed 
through  the  stricture,  and  upon  this  a  tenotomy  knife  is  guided, 
and  the  stricture  incised.  The  catheter  is  again  introduced,  and 
carried  on  to  the  bladder. 

The  simplest  and  safest  operation  of  this  kind  is  that  which  has 


STEICTUEE  OF  THE  URETHEA.  309 

been  recommended  by  Mr.  Cock,  and  which  he  calls  "tapping 
the  urethra  at  the  apex  of  the  prostate,  unassisted  by  a  guide- 
staff." 

The  operator  introduces  his  left  forefinger  into  the  rectum, 
takes  the  hearings  of  the  prostate,  and  lodges  his  finger  on  the 
apex  of  the  gland ;  then  he  Incises  the  perineum  with  a  broad 
double-edged  knife,  taking  care  to  make  the  incision  exactly  in 
the  middle  line  of  the  body,  and  to  carry  the  point  of  the  knife 
towards  the  tip  of  his  own  left  forefinger.  Thus  he  can 
hardly  fail  to  open  the  urethra  immediately  in  front  of 
the  prostate.  The  superficial  incision  is  then  enlarged  by  an 
upward  and  downward  movement  of  the  knife.  The  knife  is 
withdrawn,  and  a  probe-pointed  director  guided  into  the  bladder. 
Upon  this,  Syme's  perineal  catheter  is  passed  into  the  bladder,  and 
secured.  After  a  day  or  two  the  surgeon  can  explore  the 
urethra,  and  deal  with  the  stricture,  ^"^ery  probably  he  will  find 
that  he  can  pass  a  small  instrument  through  it.  (Cock,  in  Guy's 
Hospital  Reports,  1866.) 

d.  Or,  lastly,  a  full-sized  catheter  may  be  forced  through  into 
the  bladder.  But  this  must  be  regarded  as  a  very  unsafe  and  very 
unscientific  proceeding,  though  it  has  been  recommended  by  some 
high  authorities. 

But,  supposing  that  the  stricture  is  not  impermeable,  that  a 
small  instrument  can  be  passed,  though  with  difiiculty,  what 
ought  to  be  the  subsequent  treatment  ? 

A  great  variety  of  instruments  have  been  invented  for  the  pur- 
pose of  rapidly  restoring  the  urethra  to  its  natural  calibre.  Some 
of  these  stretch  the  stricture,  others  rupture  it  forcibly,  while 
others  incise  it  from  its  inner  aspect.  It  may  here  sufiice  to 
mention  Sir  H.  Thompson's,  Mr.  Holt's,  and  M.  Maisonneuve's 
instruments,  as  representatives  of  these  several  methods. 

But  it  may  be  confidently  asserted  that  no  plan  of  treatment  is 
so  safe,  or  so  generally  applicable,  as  the  gradual  dilatation  by 
catheters.  One  or  two  instruments  may  be  introduced  every 
alternate  day;  and  if  the  largest  size  which  is  passed  is  allowed 
to  remain  in  the  stricture  for  half  an  hour  or  so,  it  promotes  ab- 
sorption of  the  thickened  tissues,  and  facilitates  the  introduction 
of  a  larger  instrument  on  the  next  occasion.  In  this  way  No.  10 
may  be  passed  without  difficulty  in  the  course  of  two  or  three 
weeks.  When  this  happy  result  has  been  obtained,  the  patient 
should  be  warned  that  his  stricture  is  almost  certain  to  return, 
unless  he  has  a  full-sized  catheter  passed  at  least  once  a  month. 

In  the  case  of  cartilaginous  "  resilient"  strictures,  Mr.  Syme 
recommended  dividing  the  constriction  from  its  outer  aspect 
(^perineal  section).     A  small  staff,  grooved  on  its  under  surface. 


310 


DISEASES  OF  TISSUES  AND  ORGANS. 


is  passed  throug-h  the  stricture.  A  deep  incision  is  then  made  in 
the  middle  line  of  the  perineum,  the  hack  of  the  knife  being 
turned  towards  the  rectum.  The  point  of  the  blade  is  intro- 
duced into  the  groove  on  the  further  side  of  the  stricture,  which 
is  divided  as  the  knife  is  withdrawn.  A  full-sized  catheter  is 
then  passed  into  the  bladder,  and  fastened  by  tapes. 

In  many  operations  upon  the  pelvic  organs  it  is  necessary  to 
fasten  a  catheter  into  the  bladder.  I  may  therefore  take  this 
opportunity  of  explaining  the  various  ways  in  which  it  may  be 
done. 

To    retain   a  Catheter  in  the  Male  Bladder. — The  surgeon 
having  ascertained  that  the  catheter  is  in  the  required  position, 
attaches  two  pieces  of  narrow  tape  to  the  rings  of  the  instrument, 
brings  them  down  one  on  each  side  of  the  penis,  and  secures  them 
by  a  strip  of  adhesive  plaster  passing  round  the  organ.     Or  the 
same  object  may  be  effected   in  the  following  manner : — The 
surgeon  first  applies  a  single  turn  of  bandage  round  the  patient^s 
waist.     Next  he  takes  an  ivory  ring  of  suitable  size,  and  to  this 
he  attaches  four  pieces  of  narrow  tape,  each  about  ■«.  yard   long. 
He  then  passes  the  ring  down  to  the  root  of  the  penis,  and 
brings  two  of  the  tapes  up  in  front,  one  along  each   groin,  and 
fastens  them  to  the  waistband.     The  other  two  tapes  he  conducts 
backwards,  under  the  perineum,  across  the  fold  of  the  buttock, 
and  ties  them  to  the  waistband.     In  this  way  the  ring  is  secured, 
and  affords  a  fixed  point  to  which  the  catheter  may  be  attached. 
In  both  instances  the  knots  should  be  placed  at  the  patient's 
sides,  for  in  this  situation  they  will  cause  him  no  discomfort,  and 
the  surgeon  will  be  able  to  reach  them  without  difficulty.     A 
similar   piece  of  tape,  about  half  a  yard 
long,  is  then  attached  by  its  centre  round 
the  neck  of  the  catheter,  or  fastened  to  its 
rings,  and  the  ends  are  brought  down,  one 
on  each  side,  and   tied   to  the  ivory  ring 
(Fig.   138).     By  this  means  the  catheter 
may  be  removed   by  merely  untying  the 
tapes  which  fasten  it  to  the  ring.      If  a 
silver  catheter  is  used,  care  should  be  taken 
not  to  force  the  instrument  so  far  into  the 
bladder  as  to  press  against  the  posterior 
wall.     The  surgeon  should   see   that    the 
orifice  of  the  catheter  is  furnished  with  a 
wooden     peg,     which     the     patient     may 
remove    at    pleasure   when    he   wishes  to 
evacuate  the  urine.     This  will  be  found  more  convenient  than  an 
ordinary  atylet,  and  can  easily  be  supplied. 


Fig.  138. 


EXTEAVASATION  OF  URINE.  311 

To  retain  a  Catheter  in  the  Female  Bladder. — A  X-^^ndage, 
the  vertical  portion  of  which  has  been  split  into  two  tails,  is 
applied  to  the  patient  in  the  usual  waj;  ;  and  the  tails  are  brought 
up,  one  on  each  side  of  the  vulva,  care  being  taken  to  put  a  little 
cotton-wool  between  them  and  the  labia  externa,  to  prevent 
excoriation.  The  catheter  ought  then  to  be  introduced  into  the 
bladder,  and  a  piece  of  narrow  tape,  about  half  a  yard  long,  tied 
by  its  centre  round  the  neck  of  the  instrument.  The  ends  of  the 
tape  are  brought  down,  one  on  each  side,  and  tied  to  the  tails  of 
the  X-bandage  at  the  point  where  they  pass  the  orifice  of  the 
urethra.  Or  the  X^^andage  may  be  dispensed  with,  a  gum- 
elastic  instrument  used,  and  the  free  end  fastened  to  the  patient's 
thigh  by  a  broad  strip  of  adhesive  plaster. 

After  a  catheter  has  been  tied  into  the  bladder  of  either  a 
male  or  a  female  patient,  it  may  be  necessary  to  make  some  ar- 
rangement whereby  the  bedclothes  may  be  raised,  and  kept  from 
pressing  upon  the  end  of  the  instrument.  This  may  be  done  by 
means  of  a  cradle,  such  as  that  represented  in  Fig.  73  ;  or,  if  such 
a  thing  is  not  at  hand,  an  apparatus  may  be  made,  which  answers 
all  practical  purposes,  by  taking  a  bandbox,  from  which  the 
bottom  has  first  been  removed,  cutting  it  up  the  side,  and  then 
stretching  it  across  the  patient's  hips. 

EXTRAVASATION-  OF  URIITE 

may  proceed  either  from  the  bladder  or  from  the  urethra. 

The  bladder  may  give  way  from  ulceration,  or  it  may  be 
wounded  in  surgical  operations,  or  it  may  be  lacerated  by  direct 
violence.     But  such  injuries  are  comparatively  rare. 

When  the  urethra  bursts,  it  is  generally  as  a  consequence  of 
retention  following  stricture,  or  from  external  injury. 

Symptoms  of  extravasation  from,  retention. — The  patient  is  con- 
scious that  something  has  given  way,  perhaps  while  he  was  strain- 
ing. The  rupture  is  invariably  in  front  of  the  posterior  layer  of 
the  triangular  ligament.  The  immediate  feeling  is  one  of  relief. 
Soon,  however,  the  scrotum  and  lower  part  of  the  belly  become 
infiltrated  with  urine.  The  skin  is  stretched,  feels  doughy,  crepi- 
tates, and,  if  relief  is  not  afforded,  rapidly  runs  into  sloughs.  At 
the  same  time,  there  is  great  prostration,  with  inflammatory 
symptoms  of  an  asthenic  kind — a  brown  tongue  and  a  tendency 
to  muttering  delirium. 

If  the  extravasation  arises  from  injury,  the  rupture  may  be 
situated  in  the  bladder,  or  in  any  part  of  the  urethra.  If  it  is 
behind  the  posterior  layer  of  the  triangular  ligament,  the  outward 
signs  may  be  less  distinct  than  when  it  is  in  front  of  that  point, 
but  the  case  v/ill  be  more  certainly  fatal. 


312  DISEASES  OF  TISSUES  AND   ORGANS. 

The  treatment  must  be  prompt  and  vigorous.  Free  incisions 
should  be  made  through  the  skin,  wherever  the  tissues  are  infil- 
trated, so  as  to  give  vent  to  the  extravasated  urine.  Poultices 
should  be  applied  to  promote  the  separation  of  the  sloughs,  and 
afterwards  water-dressing  or  stimulating  lotions.  If  possible,  a 
catheter  should  be  passed  at  once.  If  this  cannot  be  done,  the 
urethra  should  be  opened  from  the  perineum,  by  one  of  tbe 
operations  which  have  already  been  described,  the  stricture  being 
dealt  with  at  the  same  time,  or  subsequently,  as  the  surgeon  may 
think  fit.  The  diet  should  be  liberal,  including  beef-tea,  eggs, 
and  wine  or  brandy  (F.  100,  107).  The  medical  treatment 
should  be  stimulating  and  supporting,  as  there  is  a  great  tendency 
to  death  by  exhaustion  (F.  34,  35,  42). 

ITRIIUARir  ABSCESS 

is  a  frequent  result  of  stricture.  It  may  arise  from  irritation,  or 
it  may  be  caused  by  the  escape  of  urine  into  the  submucous  cel- 
lular tissue,  in  consequence  of  ulceration.  In  either  case,  an 
abscess  forms  in  the  immediate  neighbourhood  of  the  urethra, 
sometimes  communicating  with  it  from  the  first.  Such  abscesses 
may  occur  at  any  part  of  the  urethral  canal,  but  they  are  most 
common  near  the  bulb  {^perineal  abscess).  The  symptoms  are 
those  of  acute  abscess. 

Treatment. — T\Tien  the  abscess  is  situated  behind  the  line  of 
the  scrotum,  it  should  be  opened  by  a  free  and  early  incision,  for 
fear  the  matter  burrows  in  a  backward  direction  towards  the 
neck  of  the  bladder.  If  a  stricture  exists,  it  should  be  dilated  as 
soon  as  possible. 

TTRXN-AKV  FZSTUIiil. 

often  forms,  more  especially  in  the  perineum  {fistula  in  perineo), 
as  a  consequence  of  stricture  or  urinary  abscess.  A  fistulous 
track  exists  between  the  urethra  and  the  skin,  and  by  this  the 
urine  dribbles  away  whenever  the  patient  makes  water. 

Treatment. — The  first  thing  is  to  dilate  the  urethra,  so  as  to 
establish  the  natural  channel  for  the  urine.  The  next  point  is  to 
close  the  fistula.  This  is  often  a  work  of  no  small  difficulty. 
Sometimes,  when  the  fistula  is  narrow  and  recent,  the  use  of  a 
stimulating  lotion,  or  the  application  of  caustic,  or  of  a  red-hot 
wire,  may  lead  to  its  contraction.  More  frequently,  however,  the 
sinuses  will  have  to  be  laid  open,  and  an  attempt  made  to  heal 
them  from  the  bottom.  If  the  fistula  is  in  front  of  the  scrotum, 
the  introduction  of  a  small  crystal  of  nitrate  of  silver  sometimes 
effects  a  cure,  but  more  often  a  urethro-plastic  operation  will  be 
required. 


313 


IlO-FXiAIVIAIATION'   OF  THE  PROSTATS. 

The  prostate  is  liable  to  be  acutely  inflamed.  The  most  com- 
mon causes  of  this  afiection  are  gonorrhoea,  blows  on  the  peri- 
neum, irritation  of  the  genital  organs  or  about  the  rectum,  and 
exposure  to  cold  and  wet. 

The  symptoms  are  pain  and  heat  in  the  situation  of  the  prostate, 
tenderness  on  deep  pressure  in  the  perineum,  frequent  calls  to 
make  water,  with  some  difliculty  in  doing  so.  Evacuation  of  the 
bowels  is  attended  with  pain. 

Treatment. — The  patient  should  be  confined  to  bed,  and  the 
part  well  fomented.  Leeches  may  be  applied  to  the  perineum 
with  great  advantage,  and  opiate  enemata  introduced  into  the 
rectum  (F.  90).  If  there  is  retention  of  urine,  a  flexible  catheter 
must  be  passed  from  time  to  time,  as  occasion  may  require. 

Abscess  of  the  prostate  sometimes  occurs  as  a  consequence  of 
acute  inflammation.  When  this  happens,  an  early  incision  should 
be  made  through  the  perineum,  to  prevent  the  abscess  from 
bursting  either  into  the  rectum  or  urethra. 

In  this,  and  in  all  acute  diseases  about  the  pelvic  organs,  the 
patient  should  be  confined  to  bed.  The  horizontal  position  and 
the  equable  warmth  do  much  to  promote  his  recovery. 

ENIiARGEXVIEM-T  OF  THE  PROSTATE 

is  by  no  means  uncommon  in  advanced  life. 

The  muscular  fibre,  which  forms  the  larger  portion  of  the 
gland,  becomes  simply  hypertro- 
phied.  Sometimes  it  enlarges 
imifoi-mly  ;  sometimes  one  side,  one 
lateral  lobe,  increases  more  than 
the  other.  Sometimes  the  enlarge- 
ment is  chiefly  in  the  central  and 
posterior  part,  between  the  ejacula- 
tory  ducts,  forming  what  has  been 
called  the  "middle  lobe."  Fig. 
139,  taken  from  a  preparation  in 
the  museum  of  Charing  Cross 
Hospital,  shows  the  enlargement  of 
this  middle  lobe,  and  the  consequent 
hypertrophy  of  the  bladder.  In 
any  case,  the  course  and  dimensions 
of  the  urethra  are  altered.  The 
curve  which  it  forms  as  it  enters 
the     bladder     is     increased     and 


Fiff.  139. 


Enlarged  prostate  and 
hj-pertrophied  bladder. 


314  DISEASES  OF  TISSUES  AND   ORGANS. 

lengthened.  If  the  enlargement  is  confined  to  one  lateral  lobe, 
the  urethra  will  be  twisted ;  if  it  is  in  the  posterior  median 
portion,  then  the  passage  will  be  flattened,  compressed,  and  closed 
as  it  wei'e  by  a  valve. 

Symptoms. — The  water  is  passed  slowly  and  with  straining. 
There  are  frequent  calls  to  micturate,  but  it  is  impossible  for  the 
patient  to  empty  his  bladder  altogether,  on  account  of  the 
mechanical  impediment.  A  residuum  of  urine  is  left,  which  de- 
composes, and  excites  disease  in  the  coats  of  the  bladder,  giving 
rise  to  great  pain  and  distress.  Occasionally,  there  may  be  acute 
attacks  of  inflammation,  or  complete  retention.  On  examination 
per  rectum  the  surgeon  feels  that  there  is  enlargement ;  and  if 
he  attempts  to  pass  an  ordinary  catheter,  he  meets  with  difficulty 
and  obstruction. 

The  treatment  is  merely  palliative.  A  flexible  catheter  should 
be  passed  from  time  to  time  in  order  to  draw  off  the  residual 
urine.  If  this  meets  with  obstruction,  the  surgeon  should  try 
a  gum-catheter,  mounted  on  a  stylet.  By  withdrawing  the 
stylet,  while  he  pushes  on  the  catheter,  he  can  increase  the  curve 
of  the  instrument,  and  very  probably  it  will  pass  into  the  bladder. 
If  a  silver  instrument  is  preferred,  it  should  have  a  large  curve 
and  a  long  shaft.     The  soft  French  "  elbowed"  catheter  is  very 

suitable  to  some  cases  (Fig. 
Fig.  140.  140).     The  patient  may  per- 

haps be  taught  to  pass  an 
instrument  for  himself.  He 
should  support  himself  on 
his  hands  and  knees  while 
the  water  is  escaping.  If 
the  coats  of  the  bladder 
have  become  aflected,  they 
must  be  treated  in  the  way 
Elbowed  catheter.  that    will    be    explained   in 

speaking  of  the  diseases  of 
that  organ.  When  complete  retention  occurs,  it  may  be 
necessary  to  tap  the  bladder  above  the  pubes,  or  to  puncture 
through  the  rectum,  or  to  force  a  passage  through  the  prostate. 
But  the  last-named  operation,  though  sanctioned  by  high  autho- 
rity, is  not  regarded  with  favour  by  modern  surgeons.  The  bowels 
should  be  regulated,  and  excesses  of  all  kinds  should  be  avoided,  so 
that,  as  far  as  possible,  inflammatory  attacks  may  be  prevented. 

ACUTE  IITFIiAIMEniATZOir  OF  THE  BXiADDER 

{actUe  cystitis)  may  arise  spontaneously,  or  from  neglected 
gonorrhoea,  or  from  the  unskilful  use  of  instruments.      As  an 


CHRONIC  INFLAMMATION  OF  THE  BLADDEE.    315 

idiopathic  disease  it  is  rarely  seen,  and  then  it  is  probably  of  a 
gouty  character.  Sir  H.  Thompson  thinks  it  is  sometimes  due 
to  infection  conveyed  by  the  use  of  catheters  that  have  not  been 
thoroughly  cleaned ;  and  he  recommends  that  all  instruments 
which  are  introduced  into  the  bladder  should  be  smeared  with 
carbolised  oil.  The  following  is  the  formula  which  he  suggests  : 
— R)  Acidi  carbolic!  med.  gr.  xij. ;  olei  olivse  3J  {Brit.  Med. 
Jour.,  May  10,  1879). 

Symptoms. — There  is  pain,  which  extends  to  the  sacrum,  the 
perineum,  and  along  the  urethra,  with  tenderness  on  deep  pressure 
over  the  pubes.  The  water  is  passed  frequently,  with  pain  and 
difficulty;  and  when  the  bladder  is  emptied,  the  symptoms  are 
aggravated  rather  than  relieved.  At  first,  the  urine  contains 
only  mucus,  but  afterwards  it  is  mixed  with  pus  and  blood. 
There  is  great  constitutional  disturbance,  with  mental  depression 
and  irritability, 

Treatment. — The  patient  must  be  confined  to  bed,  and  re- 
stricted to  a  low  diet.  Leeches  should  be  applied  to  the  lower 
part  of  the  abdomen.  Fomentations  and  warm  hip-baths  should 
be  used,  a  free  purge  should  be  given,  followed  by  gentle  laxatives. 
Opium  should  be  administered,  both  by  the  mouth  and  in  suppo- 
sitories (F.  90).  Sir  H.  Thompson  recommends  injecting  the 
bladder  with  borax  and  glycerine  in  warm  water  (F.  9j. 

CBRON-IC  XNFIiiilMCniATIOia-  OF  THE  BIiABDER 

{chrome  cystitis,  catarrhus  vesiccB)  generally  depends  upon  stric- 
ture, enlarged  prostate,  stone  in  the  bladder,  or  disease  of  the 
rectum  or  kidneys.  It  may,  however,  arise  spontaneously,  and 
then  it  is  probably  due  to  gout  or  scrofula  in  the  system. 

Symptoms. — There  is  frequent  and  painful  micturition.  The 
urine  contains  a  large  quantity  of  viscid  mucus,  mixed  with 
pus  and  streaked  with  whitish  lines  of  phosphate  of  lime. 
Subsequently,  as  the  disease  progresses,  the  secretion  becomes 
brownish,  ammoniacal,  and  very  offensive.  The  mucous  coat 
may  become  ulcerated,  and  then  there  will  be  blood  in  the  urine, 
with  great  aggravation  of  pain.  The  muscular  coat  becomes 
hypertrophied  or  sacculated,  and  perhaps  encrusted  with  phos- 
phate of  lime.  Ultimately  the  disease  may  extend  to  the  kidneys, 
and  then  death  cannot  be  long  delayed. 

Treatment. — The  cause  should,  if  possible,  be  removed — stric- 
ture dilated,  stone  taken  away.  Disease  of  the  kidneys  or  pros- 
tate should  be  palliated. 

The  bladder  should  be  daily  washed  out  with  warm  water,  by 
means  of  a  syringe  and  a  double-current  catheter.  Or — and  this  is 
simpler  and  better — an  India-rubber  tube  should  be  attached  to  a 


316  DISEASES  OF  TISSUES  AND  OEQANS. 

large  gum-catheter,  and  a  funnel  inserted  into  the  free  end  of  the 
tube.  The  catheter  should  then  be  passed,  the  funnel  raised, 
and  the  warm  water  poured  down  it.  When  a  sufficient  quantity 
has  made  its  way  into  the  bladder,  the  funnel  should  be  lowered, 
and  the  contents  of  the  bladder  will  escape.  This  may  be  re- 
peated as  often  as  necessary.  A  little  of  Condy's  fluid  mixed 
with  the  water  makes  a  good  wash  for  cases  in  which  the  urine  is 
very  offensive. 

Opium  and  henbane  should  be  given  by  the  mouth,  or  morphia 
or  belladonna  by  the  rectum  (F.  90),  But  if  the  kidneys  are  much 
affected,  narcotics  must  be  prescribed  with  caution.  The  medical 
treatment  should  include  the  preparations  of  buchu,  pareira,  uva 
ursi,  and  the  muriated  tincture  of  iron ;  while  the  vegetable  acids 
or  the  alkalies  are  given,  according  to  the  state  of  the  urine. 
But  of  all  medicines  the  most  valuable  in  these  cases  are  cod-liver 
oil  and  the  syrup  of  the  iodide  of  iron.  The  diet  should  be 
generous  but  unirritating,  and  should  be  accompanied  by  an 
abundance  of  simple  diluent  drinks  (F.  102,  103). 

CAITCER  OF  THE  BXiADBEXt. 

The  bladder  is  often  secondarily  affected  in  cases  of  cancer  of 
the  rectum,  but  it  may  also  be  the  primary  seat  of  disease. 
When  this  happens,  the  growth  will  be  found  to  be  either 
medullary  or  epithelial  (villous). 

The  symptoms  are  frequent  and  difficult  micturition,  and  pain 
in  the  loins,  the  lower  part  of  the  body  and  down  the  thighs,  espe- 
cially when  the  bladder  is  empty.  The  urine  is  thick,  foetid,  and 
mixed  with  blood.  If  the  sediment  is  examined  with  the  micro- 
scope, it  may  perhaps  facilitate  the  diagnosis.  If  the  bladder  is 
sounded,  no  stone  can  be  detected,  but  a  soft  mass  can  sometimes 
be  felt  projecting  from  the  wall. 

The  treatment  is  merely  palliative.  All  that  we  can  do  is 
to  support  the  strength  by  a  generous  diet  and  tonics  j  to  check 
the  tendency  to  hsemorrhage  by  styptics,  such  as  the  gallic  acid 
(F.  29)  or  the  muriated  tincture  of  iron;  and  to  allay  pain  by 
opium.  In  consequence  of  the  frequert  micturition  the  patient 
is  apt  to  become  excoriated.  Early  attention  to  this  point  may 
save  him  from  much  suffering. 

URZITARY  DEPOSITS. 

The  deposits  which  are  met  with  in  the  urine  are  chiefly  the 
following — 

1.  Minute  crystals  of  free  uric  (lithic)  acid,  or  the  urates  of 
ammonia  and  soda.     This  constitutes  the  brick-dust  or  lateritious 


UEINAEY  DEPOSITS. 


317 


Fiff.  141. 


deposit",  so  often  seen  in  inflammatory  states,  and  more  particu- 
larly in  gouty  or  rheumatic  afiections. 

2.  Oxalate  of  lime. 

3.  Phosphates  of  lime,  magnesia,  and  ammonia. 

When  any  of  these  deposits  is  habitually  present,  the  patient 
is  said  to  be  of  the  phosphatic,  the  oxalic,  or  the  lithic  acid 
diathesis.  The  deposit  may  take  place  in  the  bladder,  as  well  as 
out  of  it.  First,  minute  particles  of  gravel  are  formed,  and  these 
gradually  increase,  until  they  result  in  a  stone  {calculus). 

These  three  diatheses  correspond  to  the  three  commonest 
varieties  of  calculi  that  are  met  with  in  the  bladder — the  lithic 
acid,  the  oxalate  of  lime,  and  the  phosphatic  calculus. 

1.  The  lithic  acid  stone  is  usually  of  moderate  size,  smooth, 
flattened,  of  a  light  brown  or  drab  colour,  and  arranged  in  con- 
centric laminae  (Fig.  141).  It  is  met 
with  chiefly  in  children,  and  in  adults 
of  a  gouty  habit.  It  indicates  derange- 
ment of  the  digestive  organs  and  mal- 
assimilation,  often  from  the  use  of  an 
over-stimulating  diet.  The  tendency  to 
the  formation  of  lithic  acid  calculus  is 
shown  by  the  habitual  deposit  of  white, 
pink,  or  red  lithates  in  the  urine,  and  by 
occasional  "  fits  of  the  gravel."  These 
attacks  are  of  a  febrile  nature,  attended 
with  much  pain  in  the  loins,  sickness,  and  constitutional  dis- 
turbance. They  depend  upon  irritation  of  the  urinary  organs, 
from  the  presence  of  crystals  of  lithic  acid. 

The  general  treatment  must  consist  in  early  hours,  sufficient 
exercise,  and  a  strictly  regulated  diet,  which  is  plain  in  quality 
and  moderate  in  quantity.  The  bowels  should  be  kept  freely 
open  by  saline  aperients;  and  in  this  class  there  is  nothing 
better  than  the  natural  waters  of  Friedrich shall,  Pullna,  or 
Hunyadi-Janos.  At  the  same  time  alkaline  medicines  should  be 
prescribed  (F.  56,  64,  67),  or  a  tumblerful  of  Vichy  or  Carlsbad 
water  should  be  taken  once  or  twice  a  day.  If  the  patient  lays 
aside  the  use  of  beer,  wine,  and  spirits  altogether,  and  drinks 
instead  a  sparkling  water,  such  as  Seltzer,  or  Apollinaris,  he  will 
probably  find  himself  much  the  better. 

2.  The  oxalate  of  lime,  or  mulberry  calculus,  is  generally 
associated  with  exhaustion  of  the  nervous  system.  The  urine 
deposits  a  slight  sediment  of  octohedral  or  dumb-bell  crystals  of 
oxalate  of  lime.  The  stone  itself  is  of  a  dark  purple  or  brown 
colour,  of  a  moderate  size,  more  or  less  round,  with  a  rough  tuber- 
culated  surface,  and  very  hard. 


Lithic  acid  calculus. 


318 


DISEASES  OF  TISSUES  AND  OEGANS. 


The  oxalic  diathesis  sliould  be  treated  by  a  liglit  but  nourishing 
diet,  avoiding  sweets  and  fermented  liquors.  Tonics  should  be  pre- 
scribed, especially  the  mineral  acids,  iron  and  quinine  (P.  30,  31, 
32,  47,  65),  with  plenty  of  fresh  air  and  sunlight. 

3.  The  phosphatic  calculus  is  met  with  in  persons  of  broken 
health,  or  of  exhausted  nervous  energy.  It  is  apt  to  form 
when  there  is  disease  of  the  bladder,  and  the  urine  is  imperfectly 
voided.  It  is  sometimes  composed  of  triple  phosphate,  sometimes 
of  phosphate  of  lime,  sometimes  of  a  mixture  of  the  two.  The 
mixed  variety  is  the  commonest;  it  is  called  the  fusible  calculus, 
because  it  melts  readily  on  the  application  of  heat.  Phosphatic 
stones  sometimes  attain  great  size — the  bladder  is  filled  with  an 
irregular  chalky  mass,  which  is  easily  broken  down.  Sometimes 
they  are  only  semi-solid,  and  present  an  appearance  like  mortar. 

The  phosphatic  diathesis  should  be  treated  by  the  mineral  acids 
(F.  30,  31,  32),  a  generous  but  unirritating  diet,  and  a  regulated 
manner  of  life. 

CA3tCUIaVS  IZSr  THE  KIDSTBY. 

Calculi  not  unfrequently  form  in  the  kidney.  Sometimes  they 
remain  there,  but  more  often  they  descend  to  the  bladder. 

In  their  chemical  composition  renal  calculi  present  the  same 
varieties  as  vesical  calculi.  In  some  instances  they  are  lodged 
in  the  uriniferous  tubes,  in  others  they  lie  in  the  pelvis  of  the 
kidney.  As  they  increase  in  bulk  they  disorganize  the  proper 
renal  structure,  and  give  rise  to  an  irregular  development  of 
solid  matter  and  cysts.  Abscesses  form,  sometimes  inside,  some- 
times around,  the  kidney.     In  rare  instances  these  abscesses  have 

opened  in  the  loin,  and 


Fig.  142. 


dis- 


the  stone  has  been 
charged.  Much  more 
frequently  calculi,  while 
they  are  yet  small,  pass 
into  the  ureter.  This 
is  usually  accompanied 
by  intense  pain,  retrac- 
tion of  the  testis,  vomit- 
ing and  constipation ; 
and  is  not  relieved  till 
the  stone  reaches  the 
bladder.  If  the  calculus 
remains  in  the  kidney, 
the  patient  is  liable  to  severe  attacks  of  pain  and  sickness 
— nephritic  colic — whenever  the  stone  is  displaced,  as  it  may 
be  in  walking,  driving,  &c.     Fig.  142  represents  a  renal  calculus 


Kenal  calculus. 


CALCULUS  IN  THE  BLADDER. 


319 


Fig.  143. 


taken,  post-mortem,  from  one  of  my  patients.  The  drawing  is 
half  the  natural  size. 

Treatment. — Attacks  of  nephritic  colic  must  be  treated  by 
cupping  the  loins  or  applying  mustard  poultices,  by  hot  baths, 
and  full  doses  of  opium ;  and  the  same  treatment  must  be  pur- 
sued when  a  calculus  is  descending  along  the  ureter. 

Ever  since  the  days  of  Hippocrates  surgeons  have  discussed  the 
possibility  of  removing  renal  calculi  by  an  incision  in  the  loins ; 
and  a  few  cases  are  on  record  in  which  a  partial  or  complete 
operation  has  been  performed.  But  nephrotomy  can  hardly  yet 
be  said  to  have  taken  its  place  among  the  established  proceedings 
of  surgery. 

CAXiCUZiUS  ZUr  TBE  BZiADBEB. 

A  stone  may  either  originate  in  the  bladder  or  in  the  kidney, 
and  from  thence,  as  we  have 
said,  make  its  way  into  the 
bladder.  In  the  case  of  the 
lithic  and  oxalic  acid  calculi, 
the  nucleus  is  almost  invari- 
ably formed  in  the  kidney. 

Sometimes  there  is  but 
one  stone  in  the  bladder,  at 
other  times  there  are  many. 
When  several  calculi  are 
present  at  once,  they  rub 
against  one  another,  so 
that  their  adjacent  sides  become  flattened,  and  present  facets 
(Fig.  143). 

Calculi  generally  lie  loose  in  the  bladder,  but  it  occasionally 
happens  that  they  become  encysted  in  one  of  the  sacculi  which 
are  apt  to  be  formed  when  the  muscular  coat  becomes  hyper- 
trophied. 

Calculus  is  much  more  frequent  in  men  than  in  women.  Again, 
more  than  half  of  all  the  cases  occur  during  childhood ;  while  in 
some  countries  and  districts  the  disease  is  far  more  prevalent  than 
in  others.  Along  the  east  coast  of  England,  in  Norfolk  particu- 
larly, it  is  more  common  than  in  other  parts  of  this  country. 

Symptoms. — There  is  pain  in  the  bladder  and  perineum  ex- 
tending to  the  glans  penis,  and  down  the  legs  to  the  soles  of  the 
feet.  It  is  aggravated  by  quick  movements,  as  in  riding  or 
leaping,  especially  when  the  bladder  is  empty.  There  are 
frequent  calls  to  make  water.  The  urine  may  be  mixed  with 
mucus  or  pus,  and  it  occasionally  contains  blood.  Sometimes  the 
stone  rolls  forward  during  micturition,  so  as  to  cover  the  neck  of 


Calculi  with  facets. 


320  DISEASES   OF  TISSUES   AND   OEaANS. 

the  bladder,  and  then  the  flow  of  urine  is  suddenly  stopped. 
"  When  such  persons  (as  have  stone  in  the  bladder)  make  water," 
says  Hippocrates,  "  the  stone  forced  down  by  the  urine  falls  into 
the  neck  of  the  bladder,  and  stops  the  urine,  and  occasions  in- 
tense pain ;  so  that  calculous  children  rub  their  privy  parts,  and 
tear  at  them,  as  supposing  that  the  obstruction  is  situated 
there "  (Syd.  Soc.  Translation,  i.  201).  Sometimes  there  is 
tenesmus  and  prolapsus  recti,  more  especially  in  children ;  and 
sometimes  there  is  priapism. 

When  the  surgeon  suspects  the  presence  of  a  stone,  he  proceeds 
to  sound  the  patient.  In  the  case  of  children,  it  is  generally 
necessary  to  give  chloroform  before  this  can  be  done ;  and  in 
every  case  it  is  well  to  raise  the  patient's  hips  on  a  pillow,  so  that 
the  stone  may  gravitate  towards  the  fundus  vesicae.  The  sound 
— a  steel  instrument  with  a  narrow  shaft,  and  a  short,  curved 
and  slightly  bulbous  extremity — is  introduced  into  the  bladder. 
The  surgeon  holds  the  handle  of  the  instrument  lightly  but  firmly, 
and  by  a  series  of  short,  quick  movements  of  the  wrist  he  gently 
taps  the  wall  of  the  bladder  with  the  end  of  the  sound.  The 
examination  should  be  systematic.  The  surgeon  should  advance 
the  sound  to  the  further  part  of  the  bladder,  which,  if  the 
patient  is  well  placed,  will  also  be  the  most  dependent.  If  he 
fails  to  find  the  stone  here,  he  should  slowly  withdraw  the  sound, 
tapping  (let  us  say)  on  the  right  hand  side  as  he  does  so.  Then  he 
should  repeat  the  same  steps,  tapping  on  the  left  hand.  Thus, 
the  whole  floor  of  the  bladder  will  be  systematically  explored. 

If  the  stone  should  happen  to  be  lodged  behind  an  enlarged 
prostate,  or  above  the  pubes,  or  if  it  should  be  encysted,  there 
may  be  difficulty  in  detecting  it. 

When  the  point  of  the  sound  touches  the  stone,  the  hand  is 
conscious  of  contact  with  a  hard  body.  By  tapping  on  the  stone 
a  clear  note  may  be  produced,  which  is  distinctly  audible,  and 
which  is  very  characteristic.  By  a  skilful  use  of  the  sound  the 
position  and  size  of  the  stone  may  be  estimated.  A  stone  of 
moderate  dimensions  may  be  accurately  measured  by  means  of  a 
lithotrite — much  in  the  same  way  that  the  shoemaker  measures 
the  foot  with  his  rule. 

If  a  stone  is  allowed  to  remain  in  the  bladder,  it  is  apt  to  cause 
enlargement  of  the  prostate,  and  serious  disease  of  the  coats. 
The  muscular  tissue  becomes  hypertrophied,  and  the  mucous 
membrane  t'.iickened,  congested,  and  perhaps  ulcerated. 

Treatment. — Hitherto  all  attempts  to  dissolve  calculi  by 
chemical  agents,  without  injuring  the  coats  of  the  bladder,  have 
been  unsuccessful.  It  is  therefore  necessary  either  to  cut  into 
the  bladder,  and  remove  the  stone  entire  {lithotomy)  ;  or  else  to 


LITHOTOMY.  321 

crusb  the  stone  in  the  bladder,  and   allow  the  fragments  to  be 
discharged  with  the  urine  {lithotrity). 

IiITHOTOmV, 

There  are  various  ways  of  cutting  into  the  bladder.  That 
which  will  be  here  described  is  commonly  called  the  lateral 
operation  (Cheselden's).  We  shall  suppose  that  the  patient  is  an 
adult,  and  that  the  left  side  of  the  perineum  is  to  be  cut. 

In  order  to  prepare  the  patient  for  the  operation,  he  should  be 
kept  quiet  for  a  few  days,  his  health  regulated,  and  irritability 
of  the  bladder  allayed.  The  bowels  should  be  opened  before 
the  operation  by  an  aperient,  or  the  rectum  cleared  by  an 
enema. 

The  patient  should  be  directed  to  hold  his  urine  for  a  few 
hours  before  the  operation ;  or  a  little  tepid  water  (§iv)  should 
be  injected  into  the  bladder.  He  should  be  placed  on  a  table,  or 
hard  bed,  of  convenient  height.  The  thighs  should  be  separated 
widely,  and  strongly  flexed  on  the  pelvis,  while  the  legs  are  bent 
on  the  thighs.  The  lower  extremities  are  to  be  held  in  this  posi- 
tion by  assistants,  or  tied  with  a  lithotomy  bandage.  Such  a 
bandage  used  to  be  applied  as  a  matter  of  course,  but  since  the 
introduction  of  chloroform  it  has  generally  been  dispensed  with. 
There  are,  however,  many  cases  in  which  the  surgeon  and  his 
assistants  would  be  greatly  aided  by  this  appliance.  It  can  easily 
be  adjusted  after  the  patient  is  under  the  influence  of  the  anaes- 
thetic, and  then  his  movements  are  much  more  easily  controlled 
than  they  are  without  it.  It  may  be  applied  in  the  following 
way  : — The  patient  being  placed  in  the  usual  position  for  litho- 
tomy, the  surgeon  takes  a  flannel  "  leg-bandage,"  or  a  piece  of 
worsted  webbing  about  three  yards  long,  makes  a  "  clove-hitch  " 
in  the  middle  of  it,  and  puts  it  over  one  of  the  patient's  wrists. 
He  next  places  the  patient's  hand  on  the  outside  of  the  corre- 
sponding foot,  and  proceeds  to  apply  the  two  ends  of  the  flannel 
roller  round  the  hand  and  foot,  in  such  a  way  as  to  bind  them 
securely  together.  The  roller  should  be  kept  as  flat  as  possible, 
and  the  ends  should  be  tied  in  a  bow  on  the  outer  side,  so  that 
they  may  be  readily  unfastened.  The  same  steps  are  then  repeated 
on  the  opposite  side,  and  the  bandage  is  complete.  In  cases  of 
this  kind,  Mr.  Prichard,  of  Bristol,  uses  a  very  convenient  bracelet 
and  anklet,  which  are  buckled  round  the  wrist  and  ankle  respec- 
tively, and  then  hooked  together  when  the  proper  time  has  arrived 
for  placing  the  patient  in  position. 

When  the  operation  is  about  to  be  performed,  the  patient 
should  be  so  placed  that  the  buttocks  may  project  slightly  over 
the  edge  of  the  bed,  and  the  perineum  be  freely  exposed.     The 

T 


322  DISEASES  OF  TISSUES  AND   OEGANS. 

surgeon  begins  by  introducing  a  sound,  to  naalce  sure  of  the 
presence  of  the  stone.  This  is  then  withdrawn,  and  a  full-sized 
curved  or  rectangular  staff,  grooved  on  the  left  side,  is  passed, 
and  entrusted  to  an  assistant,  who  holds  it  well  up  against  the 
arch  of  the  pubes,  in  such  a  position  as  the  surgeon  directs,  and 
at  the  same  time  raises  the  scrotum.  The  surgeon  next  takes 
his  seat  opposite  the  patient.  With  his  left  hand  he  stretches 
the  skin,  while  with  his  right  he  cuts  the  left  side  of  the  perineum. 
The  external  incision  should  begin  about  an  inch  and  a  half  above 
the  anus,  and  in  the  middle  line  of  the  body.  It  should  be  car- 
ried obliquely  downwards  and  outwards,  to  the  extent  of  about 
three  inches,  towards  a  point  midway  between  the  tuber  ischii 
and  the  anus.  By  this  incision  the  skin,  superficial  fascia,  and 
subcutaneous  fat  are  divided.  A  second  and  deeper  incision  is 
next  made  along  the  middle  portion  of  the  former  one,  by  which 
the  transversalis  perinei  muscle  is  divided,  and  the  space  lying 
between  the  accelerator  urinse  and  the  erector  penis  muscles  is 
opened.  The  forefinger  of  the  left  hand  is  then  introduced  into 
the  wound,  until  the  groove  in  the  staff  can  be  felt,  thinly 
covered  by  the  membranous  urethra.  The  point  of  the  knife  is 
then  pushed  into  the  groove,  and  carried  along  far  enough  to 
notch  the  prostate.  Into  this  slit  in  the  urethra  the  point  of  the 
left  forefinger  is  insinuated.  By  combining  slight  force  with  a 
rotatory  movement  it  is  carried  along  the  side  of  the  staff  into 
the  bladder.  The  staff  is  then  withdrawn,  the  surgeon  still 
retaining  his  finger  in  the  bladder.  A  lithotomy  forceps  is  next 
passed  along  the  side  of  the  finger  into  the  bladder,  and  the  finger 
is  withdrawn.  The  stone  is  then  seized,  and  removed.  Some- 
times a  scoop  is  found  a  more  convenient  instrument  for  with- 
drawing the  stone.  When  this  is  used,  the  calculus  is  grasped 
between  the  scoop  and  the  point  of  the  finger.  If  it  is  necessary 
to  employ  gentle  force  in  order  to  extract  the  stone,  it  should  be 
applied  very  gradually,  and  combined  with  a  rotatory  movement, 
so  as  to  stretch  the  tissues  slowly  and  evenly. 

If  there  is  free  arterial  bleeding,  it  may  be  necessary  to  apply 
one  or  two  ligatures  to  the  sides  of  the  wound.  If  there  is  con- 
tinued oozing,  the  wound  should  be  plugged  with  lint  WTapped 
round  a  tube  or  an  elastic  catheter.  At  first  the  urine  escapes 
by  the  wound  j  but  by  the  end  of  a  week  or  ten  days  it  begins 
to  pass  by  the  urethra.  If  all  goes  well  the  wound  is  generally 
healed  in  about  three  weeks. 

Lateral  lithotomy  in  children  is  a  very  successful  operation. 
In  performing  it,  the  surgeon  should  bear  in  mind  that  the 
bladder,  before  the  age  of  puberty,  lies  high  up  towards  the  ab- 
domen.    Moreover,  as  the  urethra  is  small,  the  prostate  compa- 


LITHOTRITY.  323 

ratively  undeveloped,  and  the  tissues  yielding,  care  must  be  taken 
not  to  push  the  bladder  before  the  finger. 

The  success  of  lithotomy  in  adults  depends  in  a  great  measure 
upon  the  state  of  the  bladder  and  kidneys.  If  these  organs  are 
free  from  disease,  the  result  is  much  more  likely  to  be  favourable. 
Diffuse  inflammation  of  the  cellular  tissue  about  the  neck  of  the 
bladder — often  arising  from  infiltration  of  urine — is  a  frequent 
cause  of  death.  Occasionally  patients  die  after  the  operation 
from  haemorrhage,  or  cystitis,  or  other  complications ;  but  these 
cases  are  comparatively  rare. 

Of  late  years  the  median  operation  has  been  revived  by  Mr. 
Allarton.  It  is  most  suitable  to  the  case  of  small  stones  which 
cannot  be  crushed,  or  for  foreign  bodies  in  the  bladder.  It  is 
performed  thus : — A  staff,  with  a  central  groove  on  its  convexity, 
is  introduced  into  the  bladder,  and  confided  to  an  assistant.  The 
surgeon  then  passes  his  left  forefinger  into  the  rectum,  and  feels 
the  prostate.  He  next  pushes  the  knife,  with  its  back  turned 
towards  the  rectum,  deeply  into  the  middle  line  of  the  perineum, 
about  half  an  inch  above  the  anus,  and  hits  the  groove  in  the 
staff  at  the  further  end  of  the  membranous  portion  of  the  urethra. 
Here  he  makes  a  small  incision,  cutting  from  behind  forwards, 
and  as  he  withdraws  the  knife,  he  enlarges  the  external  wound 
upwards.  He  then  introduces  the  point  of  his  finger,  or  of  a 
dilator,  into  the  incision  in  the  urethra,  and  stretches  the  pros- 
tate, until  he  can  reach  the  bladder  with  a  small  forceps. 

The  bilateral  and  the  supra-pubic  operations  are  so  seldom 
performed,  that  we  need  not  do  more  than  allude  to  them. 

DtlTHOTRITir 

is  the  name  applied  to  the  more  modern  operation  of  crushing. 
Suitable  instruments  are  introduced  into  the  bladder,  the  stone 
is  seized,  and  is  broken  into  small  fragments.  These  are  either 
removed  at  once,  or  allowed  to  make  their  way  out  with  the 
urine. 

When  it  can  be  practised,  lithotrity  is  a  safer,  as  well  as  a  less 
formidable,  operation  than  lithotomy ;  but  there  are  many  cases 
to  which  it  is  inapplicable.  For  example,  in  male  children  the 
urethra  is  too  small  to  admit  the  passage  of  the  necessary  instru- 
ments. Or,  again,  where  there  is  stricture,  or  enlarged  prostate, 
or  an  irritable  bladder,  or  when  the  stone  is  very  hard,  or  very 
large,  or  where  many  stones  are  present,  the  case  is  not  suitable 
for  lithotrity.  Probably,  also,  when  there  is  well-marked  kidney 
disease  the  risk  of  lithotrity  is,  on  the  whole,  greater  than  that 
of  lithotomy. 

The  lithotrite,  or  crushing  instrument,  is  shaped  somewhat  like 

y2 


324 


DISEASES   OF  TISSUES  AND   ORGANS. 


Fig.  144. 


a  sound.  It  has  a  handle,  and  a  long  straight  shaft  with  a  short 
curved  extremity.  It  consists  of  two  blades,  which  are  accurately 
fitted  together.  The  outer  blade  is  fixed,  and  continuous  with 
the  handle.  The  inner  blade  travels  in  a  longitudinal  groove  cut 
in  the  outer  one.  The  force  is  variously 
applied,  either  by  a  screw,  or  by  a  rack  and 
pinion  in  connexion  with  the  handle.  By 
withdrawing  the  inner  blade,  the  ex- 
tremity of  the  instrument  opens,  so  as  to 
embrace  the  stone.  The  power  is  then 
applied,  the  blade  is  pushed  home  to  its 
original  position,  and  the  stone  crushed. 
Fig.  144  represents  the  lithotrite  which  is 
commonly  used  by  Sir  Henry  Thompson, 
and  which  is  known  by  his  name. 

The  patient  should  be  directed  to  hold 
his  water  for  a  few  hours  before  the  ope- 
ration, or  his  bladder  should  be  emptied  by 
the  surgeon,  and  six  ounces  of  tepid  water 
injected.  The  hips  should  be  raised,  so 
that  the  stone  may  gravitate  towards  the 
fundus  of  the  bladder.  The  lithotrite  is 
then  introduced,  and  with  a  light  hand 
and  gentle  touch  the  surgeon  feels  for  the 
stone.  When  he  has  found  it,  he  withdraws 
the  inner  blade  sufficiently  to  include  the 
calculus  within  the  grasp  of  the  instru- 
ment, lifts  it  from  the  surface  of  the 
bladder,  and  then  applies  the  force.  If  he 
thinks  fit,  he  repeats  the  same  process  at 
once  upon  the  larger  fragments.  But, 
under  any  circumstances,  the  "  sitting" 
should  not  be  protracted.  It  is  better  to 
await  the  result  of  the  first  operation,  and 
perform  a  second,  a  third,  or  a  fourth,  if 
necessary,  at  intervals  of  a  week.  Nothing 
is  more  dangerous  than  the  prolonged  use 
of  instruments  in  the  bladder. 

Some   surgeons   extract   the   fragments 

at  the  time  of  the  operation  with  a  scoop 

constructed    on    the    same  principle  as  a 

lithotrite.     By  this  means  they  make  sure 

of  getting  rid  of  some  of  the  larger  pieces,  which  might  with 

difficulty    pass     along     the     urethra.      Others    prefer    leaving 

them  to  be  washed  out   by  the   urine.      Mr.  Clover's  suction 


PHIMOSIS.  325 

apparatus   is   a   simple   and   efficient   means   of    removing   the 
fragments. 

In  the  after  treatment  the  patient  should  he  kept  perfectly 
quiet  in  hed.  A  catheter  may  perhaps  have  to  he  passed  occa- 
sionally to  draw  off  the  water.  If  inflammatory  symptoms  arise, 
they  must  be  met  by  fomentations ;  while  pain  and  irritability 
are  allayed  by  opium. 

Stone  in  women  is  comparatively  a  rare  disease.  For  this 
several  reasons  may  be  assigned.  Their  diet  is  less  stimulating, 
the  urine  is  less  concentrated,  the  urethra  is  more  capacious,  and 
allows  small  stones  to  pass ;  and  women  are  less  subject  than  men 
to  those  diseased  states  of  the  bladder  which  often  give  rise  to 
phosphatic  concretions. 

Calculus  in  tho  female  presents  much  the  same  train  of  symp- 
toms as  in  the  male. 

Treatment. — The  stone  should,  if  possible,  be  crushed.  If 
there  is  some  reason  for  not  performing  lithotrity,  the  urethra 
may  be  dilated,  either  with  the  surgeon's  forefinger  or  with  the 
3-bladed  dilator  that  is  made  for  the  purpose.  If  this  is  insuffi- 
cient, dilatation  may  be  combined  with  a  small  incision  through  the 
anterior  part  of  the  urethra.  Or  the  bladder  may  be  opened  from 
the  vagina,  and  the  case  treated  subsequently  as  a  vesico-vaginal 
fistula.  But  it  is  much  better  to  avoid  a  cutting  operation,  if 
possible  i  for  it  is  likely  to  be  followed  by  incontinence  of  urine, 
which  may  make  the  patient  miserable  for  months  or  years. 
Even  after  dilatation,  it  will  probably  be  some  time  before  she  is 
able  to  hold  her  water. 

PHinxoszs 

means  an  abnormal  contraction  of  the  free  border  of  the  prepuce. 
It  may  be  congenital,  or  it  may  be  caused  by  the  cicatrization  of 
ulcers  or  chancres.  When  it  is  present,  the  preputial  secretion 
is  apt  to  be  retained  under  the  foreskin,  where  it  gives  rise  to 
much  irritation,  and  to  occasional  attacks  of  inflammation,  with 
discharge  (balanitis).  Phimosis  is  often  the  exciting  cause  of 
cancer  of  the  penis. 

Treatment. — Warm  water,  or  warm  water  and  glycerine,  should 
be  injected  regularly  and  habitually  under  the  foreskin.  This 
sometimes  effects  a  great  improvement.  But  in  most  cases  an 
operation  will  be  required.  If  the  foreskin  is  long  and  tight,  or 
if  it  is  thickened  by  cicatrices,  it  should  be  drawn  forward,  held 
between  the  blades  of  a  forceps,  so  as  to  protect  the  glans  penis, 
and  cut  off  evenly  by  one  sweep  of  the  knife.  If,  however,  the 
case  is  less  severe,  it  will  suffice  to  slit  up  the  prepuce  on  its 
dorsal  aspect  as  far  as  the  base  of  the  glans.    This  should  be  done 


326  DISEASES  OF  TISSUES  AND  ORGANS. 

by  introducing  an  oiled  director  underneath  the  foreskin,  and 
passing  upon  it  a  curved,  sharp-pointed  bistoury,  piercing  the 
skin,  and  cutting  from  within  outwards.  The  mucous  membrane 
will  probably  require  a  second  incision,  for  the  chief  seat  of  the 
constriction  is  there.  If  the  side-flaps  are  very  long,  a  triangular 
piece  may  be  taken  ofi"  each.  The  skin  and  mucosa  should  then 
be  united  by  continuous  or  interrupted  sutures,  and  water- 
dressing  applied.  In  young  children  it  is  hardly  necessary  to 
use  any  stitches. 

PARAPHIMOSIS. 

When  a  tight  foreskin  is  drawn  over  the  glans  and  allowed  to 
remain  there,  it  constitutes  the  condition  known  as  paraphimosis. 
The  penis  is  constricted ;  the  skin  becomes  cedematous ;  and  the 
mucous  lining  of  the  prepuce  and  glans  become  congested. 
If  this  state  of  things  is  allowed  to  continue,  ulceration  or 
sloughing  takes  place. 

Treatment. — The  surgeon,  having  oiled  the  parts,  takes  the 
penis  between  the  fingers  of  both  hands,  and  draws  the  o/)nstric- 
tion  slowly  but  steadily  forwards;  at  the  same  time,  with  his 
thumbs,  he  compresses  the  glans,  and  pushes  it  backwards.  It 
gives  the  surgeon  a  firmer  hold  on  the  penis,  if  he  wraps  a  fold  of 
lint  round  it  before  he  begins  to  make  traction  and  pressure. 
Sometimes  the  constriction  may  have  to  be  divided  with  a  knife 
before  reduction  can  be  effected. 

BVPOSPABIAS  AN-B  EPISPADIAS. 

Sometimes  the  urethra,  from  a  congenital  malformation,  ter- 
minates on  the  under  surface  of  the  penis  before  it  reaches  the 
point  of  the  glans.  This  is  termed  hypospadias.  -  When  it  pre- 
sents itself  in  a  somewhat  similar  way  on  the  dorsal  aspect,  it  is 
called  epispadias.  The  malformation  may  be  very  slight ;  or  it 
may  extend,  in  the  one  case,  to  the  scrotum ;  in  the  other, 
to  the  anterior  wall  of  the  bladder  {extroversion  of  the 
bladder). 

Treatment. — When  the  deformity  is  only  slight,  it  does  not 
interfere  with  the  natural  functions  of  the  urethra,  and  requires 
no  treatment.  When  it  is  extensive,  the  patient  may  have  to 
wear  a  mechanical  contrivance  to  protect  the  parts;  or  an 
attempt  may  be  made  to  cure  the  deformity  by  means  of  a  plastic 
operation.  Mr.  John  Wood,  Mr.  Holmes,  and  others,  have 
shown  much  ingenuity  and  skill  in  dealing  with  this  malforma- 
tion. 


327 


CAirCER  OF  THE  PEITZS 

occurs  only  in  those  who  are  advanced  in  life.  It  may  often  be 
traced  to  the  irritation  caused  by  congenital  phimosis.  It  gene- 
rally takes  the  form  of  an  epithelial  growth. 

A  small  tubercle,  or  ulcer,  forms  on  the  inner  surface  of  the 
prepuce,  spreads,  and  implicates  the  glans.  Gradually  the 
growth  increases  in  size,  until  it  presents  a  rough,  irregular  mass, 
which  discharges  an  offensive  matter.  The  lymphatics  of  the 
penis  become  swollen,  and  the  glands  in  the  groin  are  enlarged. 
If  the  orifice  of  the  urethra  is  involved,  micturition  may  be  diffi- 
cult ;  or  there  may  be  complete  retention. 

The  diagnosis  between  cancer  of  the  penis  and  gonorrhoea! 
warts  or  chancrous  ulceration  may  generally  be  made  without 
difficulty  by  attending  to  the  following  -p.     ^^^ 

points  : — Cancer  has  an  indurated  base, 
resists  treatment,  and  progresses  con- 
stantly. In  the  case  of  gonorrhoeal 
warts  there  is  a  history  of  infection, 
and  the  base  is  not  indurated  :  when 
they  are  removed,  the  mucosa  is  soft 
and  natural.  In  the  case  of  chancrous 
ulceration  there  is  a  history  of  infec- 
tion, and  the  disease  yields  to  proper 
treatment. 

Treatment. — If  the  cancer  is  small, 

it  mav  suffice  to  remove  it  by  a  free        „  ,  , , 

*•.  ,    ^    .^    ..     .     1  J        Cancer  of  the  penis, 

dissection ;    but    if   it    is   large    and 

wide-spread,   the  penis   should   be   amputated  above  the   seat 

of  disease. 

Amputation  of  the  penis. — The  surgeon  takes  the  penis  in 

his  left  hand,  and  puts  it  on  the  stretch,  while  he  removes  the 

disease  with  one  sweep  of  the  amputating  knife.     The  bleeding 

points  must  be  ligatured  or  twisted.     The  mucous  membrane  of 

the  urethra  should  then  be  nicked,  so  as  to  divide  it  into  four 

equal  flaps,  and  stitched  to  the  margins  of  the  skin.     If  this  is 

done,  there  will  be  no  fear  of  the  troublesome  contraction  of  the 

orifice,  which  sometimes  follows  the  operation. 

BTSROCEIiE 

is  the  name  given  to  a  collection  of  serous  fluid  in  the  tunica 
vaginalis.  Sometimes  the  disease  is  traced  to  an  injury,  or  a 
strain,  or  an  attack  of  orchitis.  Sometimes  it  arises  without  any 
assignable  cause. 


328 


DISEASES  OF  TISSUES  AND  OEGANS. 


rig.  146. 


Hydrocele. 


Symptoms. — The  swelling  takes  place  gradually.  It  begins 
from  the  bottoni,  and  slowly  extends  upwards.  The  resulting 
tumour  has  a  pyriform  shape,  and  a  smooth,  regular  outline 
(Fig  146).  It  is  free  from  pain  or 
tenderness,  but  there  is  a  feeling  of 
weight  and  dragging.  Except  in  certain 
rare  cases,  it  does  not  disappear  when 
the  patient  lies  down.  It  is  translucent, 
elastic,  and  fluctuating.  The  testicle 
generally  lies  at  the  back,  almost  sur- 
rounded by  fluid.  It  is  never  found 
lying  free  below  the  swelling,  as  in  the 
case  of  rupture.  No  impulse  is  com- 
municated to  the  tumour  by  coughing. 
If  there  is  any  doubt  about  the  diag- 
nosis, the  tumour  should  be  examined 
by  transmitted  light.  It  should  be  care- 
fully isolated,  and  held  forward.  If  a 
lighted  candle  is  placed  on  the  further 
side,  and  the  surgeon  looks  under  the 
edge  of  his  hand  or  through  a  roll  of  paper,  he  can  generally 
make  the  diagnosis  with  certainty  and  distinguish  the  position 
of  the  testicle. 

The  fluid  consists  of  serum  of  a  pale  yellow  or  ^raw  colour ; 
sometimes  it  is  mixed  with  blood ;  and  sometimes  it  is  turbid 
with  fibrinous  flakes.  The  average  quantity  present  is  about  ten 
or  twelve  ounces.  But  sometimes  it  far  exceeds  this  measure. 
Cline  tapped  a  hydrocele  in  Gibbon,  the  historian,  and  drew  off 
six  quarts  of  fluid. 

The  treatment  is  either  palliative  or  radical.  The  palliative 
treatment  consists  in  tapping  the  swelling  simply  ;  the  radical,  in 
tapping  it  and  injecting  a  stimulating  fluid,  such  as  the  tincture 
of  iodine  or  port-wine.  By  this  means  it  would  appear  that  the 
healthy  functions  of  the  serous  membrane  are  restored. 

In  performing  the  operation  of  tapping,  the  surgeon  grasps  the 
tumour  firmly  behind  with  his  left  hand,  so  as  to  make  it  tense 
and  prominent  in  front.  He  then  pushes  the  trochar  and  canula 
in,  at  right  angles  to  the  long  axis  of  the  swelling ;  and  as  soon 
as  he  feels  that  the  point  has  entered  the  cavity,  he  directs  it 
obliquely  upwards.  He  then  withdraws  the  trochar,  and  allows 
the  fluid  to  flow  through  the  canula.  If  he  desires  to  inject  the 
sac,  a  syringe  is  fitted  to  the  canula,  the  fluid  is  thrown  in,  and 
the  canula  is  removed.  The  injection,  which  is  generally  used, 
consists  of  equal  parts  of  tincture  of  iodine  and  water — ^j  of 
each.     The  scrotum  should  be  lightly  shaken,  so  as  to  bring  the 


HYDROCELE.  329 

fluid  into  contact  with  every  part  of  the  tunica  vaginalis,  and 
there  it  should  be  allowed  to  remain.  When  a  hydrocele  is  in- 
jected, there  is  generally  a  good  deal  of  inflammation.  This  sub- 
sides in  the  course  of  a  few  days.  In  most  cases  a  radical  cure 
is  effected,  and  the  normal  balance  between  secretion  and  absorp- 
tion is  restored. 

Congenital  Hydrocele. — Infants  are  liable  to  the  ordinary 
form  of  hydrocele  ;  but  they  are  also  subject  to  a  special  variety, 
known  as  congenital  hydrocele.  The  communication  between  the 
peritoneal  cavity  and  the  pouch  which  goes  to  form  the  tunica 
vaginalis  remains  open,  and  the  fluid  occupies  the  same  place  as 
the  bowel  in  a  congenital  hernia.  The  two  diseases,  congenital 
hydrocele  and  congenital  hernia,  are  very  apt  to  occur  together. 

Treatment. — In  infants  the  ordinary  closed  hydrocele  may  be 
cured  by  the  use  of  a  discutient  lotion  (F.  18,  21).  In  the 
congenital  hydrocele  the  child  should  wear  a  truss,  so  as  to  obli- 
terate the  opening  into  the  peritoneal  cavity.  In  young  subjects 
mild  measures  almost  always  suffice,  for  nature  does  much  to 
promote  a  cure. 

Encysted  Hydrocele. — Here  the  fluid  does  not  form  in  the 
tunica  vaginalis,  but  in  a  cyst  connected  with  the  testis  or  epidi- 
dymis. Small  cysts  in  this  situation  are  very  common.  Some- 
times they  increase  to  an  inconvenient  size. 

Symptoms. — In  many  respects  they  resemble  the  common 
hydrocele.  But  they  do  not  attain  the  same  bulk,  and  they  may 
generally  be  felt  to  be  offsets  from  the  testis  or  epididymis.  It 
is  a  curious  fact  that  spermatozoa  are  often  found  in  the  fluid 
they  contain. 

Treatment. — The  cyst  may  be  simply  tapped,  or  tapped  and 
injected;  or  a  seton  may  be  passed  through  it;  or,  if  milder 
measures  fail,  it  may  be  laid  open  and  allowed  to  granulate. 

Hydrocele  of  the  Cord. — A  tumour  containing  serous  fluid 
occasionally  forms  on  the  cord,  in  or  below  the  inguinal  canal. 
Sometimes  it  is  fixed ;  sometimes  it  may  be  pushed  back  into  the 
abdominal  cavity.  It  receives  no  impulse  from  coughing;  is 
smooth,  elastic,  and  fluctuating.  In  some  cases  it  appears  to  be 
formed  by  an  extension  of  the  pouch  of  peritoneum,  which  dips 
into  the  internal  abdominal  ring.  In  other  cases  it  seems  to  be 
developed  in  a  cyst  connected  with  the  coverings  of  the  cord. 

The  treatment  consists  in  following  the  same  general  principles 
as  in  the  foregoing  cases,  only  the  situation  of  the  disease  gives 
rise  to  a  little  difficulty.  Acupuncture  should  be  tried,  or  a 
seton  passed  through  the  swelling,  or  it  may  be  laid  open,  and 
allowed  to  granulate. 


330 


DISEASES  OF  TISSUES  AND  ORGANS. 


BSMATOCEIiS 

is  the  name  given  to  a  collection  of  blood  in  the  tunica  vaginalis. 

It  is  generally  traumatic,  the  result  of  a  blow  or  wound,  though 

it  may  arise  spontaneously.     Fig.  147  was  drawn  from  a  child, 

who  had  fallen  and  struck  his 
lig.  147.  jg£!j.    |;gg^jg   against  a  piece   of 

furniture. 

Symptoms. — The  tunica  va- 
ginalis becomes  gradually  dis- 
tended ;  the  testicle  is  com- 
pressed, and,  if  the  disease 
persists,  it  is  very  apt  to  waste. 
If  the  hsematocele  has  lasted 
for  a  considerable  time,  it  may 
attain  a  large  size,  and  the 
fibrine  of  the  blood  may  be 
deposited  in  layers  on  the  sur- 
face of  the  tunica  vaginalis,  so 
that  it  resembles  the  sac  of  an 
aneurysm. 
Treatment. — When  the  case  is  recent,  rest,  pressure,  and  dis- 
cutient  lotions  should  be  tried  (F.  18,  21).  If  these  means 
fail,  the  tumour  may  be  tapped,  or  a  wire  seton  passed  through 
it.  If  it  has  existed  for  some  time,  it  will  probably  have  to  be 
laid  open,  the  clots  turned  out,  and  the  cavity  allowed  to  granu- 
late.    As  a  last  resource,  castration  may  be  performed. 

VARZCOCEIiE 

•is  the  name  given  to  the  swelling  which  is  formed  by  a  varicose 
state  of  the  veins  of  the  spermatic  cord.  It  is  caused  by  anything 
which  retards  the  venous  circulation — e.g.,  debility,  constipation, 
&c.  The  left  side  is  more  often  affected  than  the  right ;  partly 
because  the  veins  of  the  left  side  are  longer  than  those  of  the 
right,  and  partly  because  they  are  subject  to  the  pressure  of  the 
distended  sigmoid  flexure  of  the  colon. 

Symptoms. — A  swelling  is  felt,  which  has  been  aptly  compared 
to  worms  in  a  bag.  It  is  irregularly  pyramidal,  its  base  resting 
on  the  testis,  and  its  apex  pointing  to  the  external  abdominal 
ring.  It  subsides  to  a  great  extent  when  the  patient  lies  down, 
but  soon  returns  when  he  stands  up.  It  is  accompanied  by  a 
sensation  of  weight,  and  dragging  pain  in  the  back  and  loins. 
These  feelings  are  aggravated   when   the  patient  takes  active 


ACUTE  INFLAMMATION  OF  THE  TESTIS.       331 


exercise.  After  it  has  existed  for  some  time  it  is  apt  to  cause 
atrophy  of  the  testicle  (Fig.  148). 

Treatment. — The  disease  may  be  palliated  by  wearing  a  sus- 
pensory bandage,  and  bathing  the  parts  frequently  with  cold 
water.      At     the    same    time,    the 
general  health   should  be  improved 
by  tonic  medicines  (F.  47,  52,  65). 

The  radical  cure  of  varicocele  is 
effected  by  obliterating  the  veins, 
on  the  same  principle  that  we  treat 
varix  of  the  lower  extremity.  Our 
object  is  to  compress  the  coats 
of  the  veins,  so  as  to  excite  adhesive 
inflammation.  If  the  compressing 
force  is  continued,  the  coats  ulcerate, 
and  are  divided  at  the  point  of 
pressure.  A  great  many  methods 
are  practised,  but  the  principle  is 
the  same  in  all.  Some  pass  a  hare- 
lip pin  underneath  the  veins,  and 
then  twist  a  thick  silk  over  it,  in  the 

form  of  a  figure-of-8.  Others  put  a  noose  of  silver  wire  round  the 
veins  by  means  of  a  needle,  which  enters  the  scrotum  and  emerges 
at  the  same  point,  and  then  twist  it,  so  as  to  compress  them. 
A  few  turns  are  given  to  the  wire  every  day,  and  thus  it  soon 
cuts  its  way  out.  Some  tie  the  veins  in  two  places,  and  divide 
them  subcutaneously  between  the  ligatures.  But  this  seems  to 
be  both  unnecessary  and  hazardous,  and  should  never  be  done. 

Before  undertaking  any  of  these  operations,  the  spermatic 
cord  should  be  carefully  held  aside  by  an  assistant.  It  may  be 
easily  distinguished  by  its  hard,  even  feeling,  like  whipcord. 

ACUTE  USTItAVtatlAT'LOSi  OF  THE  TESTIS. 

Orchitis. — The  testicle  is  liable  to  both  acute  and  chronic 
inflammation.  The  acute  variety  is  most  often  seen  as  an  accom- 
paniment of  gonorrhoea  ;  but  it  may  also  result  from  blows,  or  it 
may  arise  in  the  course  of  small-pox  or  mumps  or  gout. 

Symptoms. — There  is  pain,  with  a  dragging  sensation  in  the 
cord,  heat,  swelling,  redness,  exquisite  tenderness,  pains  in  the 
back,  loins,  and  perineum.  Pressure  with  the  point  of  the  finger 
causes  intense  sickening  pain.  There  is  great  constitutional 
disturbance,  with  nausea  and  vomiting.  When  the  attack  is 
connected  with  gonorrhoea,  the  inflammation  extends  along  the 
vas  deferens ;  and  then  it  would  appear  to  be  the  epididymis 
which  is  chiefly  affected  {epididymitis).     The  discharge  from  the 


332 


DISEASES   OF  TISSUES  AND  OKGANS. 


Fig.  149. 


urethra  generally  ceases  while  the  inflammation  in  the  testis  is  at 
its  height.  This  seems  to  be  due  to  counter-irritation,  and  not 
to  metastasis. 

Treatment. — Perfect  rest  in  bed  must  be  enjoined,  and  the 
testis  raised  on  a  small  pillow.  Fomentations — plain  or  medi- 
cated— should  be  assiduously  ap- 
plied. If  the  tunica  vaginalis  is 
much  distended,  the  fluid  may  be 
evacuated  by  means  of  a  small 
trochar.  At  the  same  time,  purga- 
tives and  diaphoretics  should  be 
given,  with  opium  to  allay  pain  and 
procure  sleep  (F.  53,  64,  69). 

When  the  acute  stage  has  passed, 
and  nothing  remains  but  hardness 
and  swelling,  the  scrotum  should  be 
supported  by  a  suspensory  bandage. 
Strapping  the  testicle  evenly  and 
firmly  will  also  be  found  of  the 
greatest  benefit. 

Bandages  for  supporting  the 
Scrotum. — The  scrotum  may  be 
supported  in  various  wajs.  A  sus- 
pensory bandage,  such  as  those 
which  are  sold  at  the  instrument 
makers,  is  perhaps  the  best. 
But  if  it  is  impossible  to  get  one  of  these,  or  if  the  scrotum  is  so 
much  enlarged  that  it  cannot  be  contained  in  one,  a  very  useful 
substitute  may  be  made  with  a  broad  roller  and  a  handkerchief. 
The  roller  is  passed  round  the  waist,  and  fastened  in  front.  The 
handkerchief  should  then  be  folded  in  a  triangular  form,  and  the 
centre  of  the  base  of  the  triangle  applied  to  the  perineum  behind 
the  scrotum.  The  corresponding  ends  are  now  drawn  up,  one  on 
each  side  of  the  scrotum,  and  tied  to  the  waistband  in  the  way 
represented  in  Fig.  149.  The  apex  of  the  triangle  is  then 
brought  up  in  front  of  the  scrotum,  passed  round  the  waistband, 
and  fastened  with  a  pin  or  in  a  knot. 

CKROiriC  ZIO-FIiAIVIlVIATZON-  OF  THE  TESTIS 

{chronic  orchitis)  may  follow  an  acute  attack,  or  it  may  be  caused  by 
disease  of  the  urethra,  or  it  may  depend  upon  a  syphilitic  taint. 

Symptoms. — The  testicle  becomes  enlarged  and  hardened. 
There  is  but  little  pain  or  tenderness.  The  whole  organ  is 
generally  affected  equally.  There  is  usually  more  or  less  effusion 
into  the  tunica  vaginalis.     One  or  both  testicles  may  be  the 


Handkerchief  bandage  for 
the  scrotum. 


CHEONIC  INFLAMMATION   OF   THE  TESTIS.     333 


Fig.  150. 


seat  of  disease.     There  is  deposit  of  yellow,   cbeesy,  fibrinous 
matter  in  and  between  tbe  tubules. 

Treatment. — If  there  is  disease  of  the  urethra,  we  must  endea- 
vour to  cure  it,  and  then  the  inflammation  of  the  testicle  will 
subside  by  itself.  If  there  is  a 
syphilitic  taint,  blue  ointment  should 
be  rubbed  in  locally,  while  a  mild 
course  of  mercury,  or  of  the  iodide  of 
potassium,  is  given  (F.  49,60).  Some- 
times small  doses  of  grey  powder,  or  of 
corrosive  sublimate,  with  tonics,  may 
promote  the  absorption  of  the  effused 
material  (F.  50).  Whatever  remedies 
are  tried,  rest  in  the  horizontal  posi- 
tion, support  by  means  of  a  suspensory 
bandage,  and  even  pressure  by  strap- 
ping, should  always  be  used. 

Strapping  the  Testicle. — This  is 
generally  done  in  the  following 
manner  : — First  of  all  the  enlarged 
testis  is  separated  from  the  rest 
of  the  scrotum,  and  a  strip  of  wash- 
leather  plaster,  about  an  inch  in 
breadth,  is  rolled  round  the  sper- 
matic cord  and  vessels,  so  as  to  form 
a  collar  which  isolates  the  testicle. 
The  surgeon  then  prepares  a  number  of  strips  of  the  ordinary 
diachylon  plaster,  about  an  inch  wide,  and  long  enough  to  go 
once  and  a  half  round  the  affected  part.  These  should  be  well 
warmed  or  dipped  in  hot  water,  and  then  applied  to  the  testicle 
in  regular  order  (Fig.  150).  The  first  two  or  three  strips 
should  be  laid  on  vertically,  from  behind  forwards,  and  tight 
enough  to  exert  a  slight  degree  of  compression.  Then  a  sufficient 
number  of  strips  should  be  placed  in  the  same  way,  from  side  to 
side,  beginning  on  the  inside,  passing  round  the  lowest  point  of 
the  testis,  and  terminating  on  the  outside.  If  any  intervals  are 
left  between  these  vertical  strips,  they  should  be  covered  in  a 
similar  manner,  after  which  the  plaster  should  be  rolled  in  a 
circular  or  spiral  way  round  the  testicle,  until  it  has  been  com- 
pletely and  firmly  enveloped.  In  the  course  of  a  few  days  it 
will  be  found  that  the  strapping  has  become  loose,  and  then  it 
must  be  removed,  and  fresh  plaster  applied. 

Strapping  is,  at  best,  rather  a  rough  method  of  compressing 
the  testicle.  To  be  effectual  it  must  be  renewed  every  few  day, 
and  the  removal  of  the  plaster  is  often  a  very  painful  process 


Strapping  the  testicle. 


334  DISEASES   OF  TISSUES  AND  OEGANS. 

The  same  object  may  be  effected  more  conveniently  in  another 
way.  After  the  testis  has  been  isolated  by  a  collar  of  leather 
plaster,  in  the  manner  described,  a  piece  of  flannel  or  stocking- 
bandage  is  taken,  large  enough  to  envelop  the  tumour.  This  is 
folded  round  the  testicle,  and  a  running  lace  made  in  it  with  a 
needle  and  a  stout  silk  thread.  By  this  means  a  sort  of  body- 
bandage  is  applied,  which  can  be  tightened  or  loosened  at 
pleasure,  which  is  cleanly,  and  which  can  be  removed  without 
pain  or  diflBculty. 

Sometimes  the  inflamed  testicle  softens  at  one  point ;  an  abscess 
forms  and  bursts,  or  is  opened.  When  this  happens,  the  tubular 
structure  of  the  gland  is  apt  to  protrude  as  a  fungus  (hernia 
testis).  In  such  a  case,  pressure  should  be  made  by  means  of  a 
pad,  or  the  fungus  should  be  freely  touched  with  caustic.  If  these 
means  fail,  the  case  should  be  treated  in  the  way  that  Mr.  Syme 
has  recommended.  The  skin  around  the  protrusion  should  be 
dissected  back,  the  edges  pared,  brought  together,  and  united 
over  the  fungus,  so  as  to  cover  it. 

Scrofulous  Testicle. — The  scrofulous  habit  sometimes  manifests 
itself  in  the  testicle.  A  slow  and  chronic  inflammation  takes 
place,  with  deposit  of  tubercular  matter  in  and  between  the  semi- 
niferous tubules.  The  gland  enlarges  irregularly,  without  pain 
or  tenderness,  and  its  outline  becomes  rough  and  nodulated. 
Here  and  there,  it  softens  and  breaks  down.  Abscesses  form, 
and  open  externally,  perhaps  allowing  the  structure  of  the  testicle 
to  protrude  as  a  fungus.  Such  abscesses  are  apt  to  burrow  in  all 
directions,  disorganizing  the  whole  gland,  and  giving  rise  to  an 
exhausting  discharge. 

Treatment. — The  local  disease  must  be  met  by  rest,  support, 
even  pressure,  and  absorbent  ointments.  At  the  same  time  the 
constitutional  treatment  must  on  no  account  be  omitted.  When 
abscesses  form,  they  must  be  opened,  and  the  resulting  sinuses 
treated  by  astringent  or  stimulating  lotions  (F.  14,  22,  25).  If 
the  gland  is  thoroughly  disorganized,  and  the  discharge  is  exhaust- 
ing the  patient,  the  entire  testicle  will  have  to  be  removed. 

Cystic  Sarcocele. — In  all  these  solid  tumours  of  the  testis, 
whether  the  enlargement  be  of  a  simple,  a  syphilitic,  a  scrofulous, 
or  a  malignant  kind,  cysts  are  apt  to  be  developed  by  the  dilata- 
tion of  the  seminiferous  tubules.  Such  cysts  may  vary  greatly 
in  size;  usually  they  are  about  the  size  of  a  marble.  When 
many  of  them  are  present  in  the  tumour,  it  is  called  by  the 
generic  name  of  cystic  sarcocele.  But  the  precise  nature  of  the 
solid  substance  in  which  the  cysts  are  embedded  is,  after  all,  the 
important  point  for  diagnosis. 


335 


CAXrCSR  OF  THS  TESTZCXiE 

is  generally  of  the  medullary  variety. 

The  early  symptoms  are  obscure,  because  they  are  common  to 
many  of  the  tumours  which  are  met  with  in  this  situation.  The 
testicle  enlarges  from  the  centre ;  feels  smooth,  hard,  and  heavy. 
The  patient  complains  of  a  sensation  of  weight  and  dragging. 
The  growth  makes  steady  progress.  The  skin  of  the  scrotum 
becomes  distended  and  purple.  Soon  it  becomes  adherent, 
softens,  ulcerates,  and  then  the  cancer  protrudes  in  a  fungous 
mass.  The  cord  becomes  hard  and  nodulated.  Pain,  which  is 
sometimes  of  the  characteristic  lancinating  kind,  extends  along 
the  course  of  it  towards  the  loins.  When  the  tumour  begins  to 
increase  rapidly,  there  is  no  longer  any  doubt  about  the  diag- 
nosis. The  inguinal  glands  do  not  become  affected  till  the 
disease  has  existed  for  some  time,  and  the  scrotum  is  impli- 
cated. The  pelvic  and  lumbar  glands  are  the  first  to  be- 
come enlarged,  and  may  give  rise  to  pain  in  the  back  and 
loins. 

Treatment. — As  soon  as  the  nature  of  the  tumour  has  been 
ascertained,  the  entire  testicle  ought  to  be  removed. 

Castration  is  performed  thus: — If  the  skin  is  free,  a  single 
long  incision  is  made  from  the  external  abdominal  ring  to  the 
bottom  of  the  scrotum ;  or,  if  the  skin  is  involved,  a  double 
elliptical  incision  will  be  required.  Partly  by  tearing,  and 
partly  by  a  few  light  touches  of  the  knife,  the  testicle  is  raised 
from  the  cellular  bed  in  which  it  lies.  The  upper  part  of  the 
cord  should  then  be  transfixed  with  a  hook,  or  held  by  an 
assistant,  while  the  tumour  is  cut  off".  Unless  this  is  done, 
there  is  danger  of  the  cut  end  of  the  cord  being  retracted 
within  the  inguinal  canal.  Two  or  three  bleeding  points  in  the 
cord  and  scrotum  will  have  to  be  secured  by  ligatures  or  by 
torsion.  The  wound  should  be  lightly  dressed,  and  allowed  to 
granulate. 

(EDEMA  OF  THE  SCROTUM. — KVPERTROPHV. 

Acute  oedema  of  the  scrotum  is  one  of  the  earliest  symptoms 
in  some  cases  of  cardiac  or  renal  disease.  The  patient  suddenly 
finds  his  scrotum  enlarged,  and  the  glistening  translucent 
appearance  at  once  suggests  to  the  surgeon  that  he  must 
look  to  the  heart  or  to  the  kidneys  for  the  origin  of  the 
disease. 

Solid  oedema,  hypertrophy  of  the  scrotum  (elephantiasis  Ara- 
bum),  is  of  quite  a  difierent  character.      It   is  rarely  seen  in 


836 


DISEASES  OF  TISSUES  AND  ORGANS. 


Fig.  151. 


this  country,  but  is  endemic  in  the  tropics.  Some  regard  it 
as  a  constitutional  disease,  but  probably  it  requires  also  some 
exciting  local  cause.  It  consists  essentially  of  an  overgrowth 
of  the  elements  of  the  skin  and  subcutaneous  cellular  tissue, 
with  infiltration  of  organizable  lymph.  The  part  increases  in 
size,  the  skin  becomes  coarse  and  furrowed ;  and  in  the  furrows 
cracks  and  fissures  form,  which  give  rise  to  offensive  ulcerations. 
The  prepuce  is  affected,  as  well  as  the  skin  of  the  scrotum,  so 
that  the  penis  is  quite  buried.  The  testicles  are  found  in  their 
natural  situation,  and  there  is  usually  more  or  less  hydrocele  of 
the  tunica  vaginalis.  The  hypertrophy  sometimes  goes  on  to  an 
enormous  extent. 

The  largest  tumour  of  the  kind  I  have  seen  was  that  which 
was  removed  by  Mr.  Wiblin,  of  Southampton,  and  which  weighed 

after  removal  nearly  thirty  pounds. 
But  cases  are  on  record  which  have 
weighed  five  or  six  times  as  much 
as  this.  Fig.  151  was  drawn  from 
a  man  upon  whom  Sir  W.  Fergusson 
operated,  when  I  was  his  house- 
surgeon.  The  case  is  alluded  to  in 
his  "Practical  Surgery,"  and  was 
reported  in  the  Lancet  for  Septem- 
ber 28,  1861.  The  patient  was  a 
tall,  strong  man,  a  bricklayer  by 
trade,  and  had  never  been  out 
of  England.  He  attributed  the 
commencement  of  the  disease  to  a 
blow,  eight  years  before.  The 
tumour,  after  removal,  weighed 
nearly  six  pounds.  The  operation 
was  successful,  and  several  years 
afterwards  I  saw  the  man  in  perfect 
health. 

The  only  treatment  is  by  an  operation.  Sir  Joseph  Fayrer,  in 
his  "  Clinical  Surgery  in  India,"  describes  the  best  mode  of  per- 
forming such  an  operation,  and  gives  an  analysis  of  twenty-eight 
cases. 

An  hypertrophy,  which  is  essentially  similar  in  its  character, 
sometimes  affects  the  lower  extremities  (Barbadoes  leg). 

The  accompanying  illustration  (Fig.  152)  was  drawn  from  a 
case  which  occurred  in  the  practice  of  Dr.  C.  J.  Richardson,  and 
is  fully  reported  in  the  "  Proceedings  of  the  Royal  Medical  and 
Chirurgical  Society"  for  1860.  It  was  chiefly  remarkable  because 
the  patient  was  a  young  woman  who  had  never  been  out  of  this 


Hypertrophy  of  the 
scrotum. 


YESICO-VAGINAL  FISTULA. 


337 


country.    The  disease  began  when  she  was  fourteen ;  at  the  time 
the  drawing  was  made  it  had  existed  fourteen  years. 

Fii?.  152. 


Elephantiasis  of  the  leg. 

In  the  treatment  of  these  cases  drugs  are  of  no  avail.  Ligature 
of  the  main  artery  has  sometimes  been  followed  by  excellent 
results.  It  acts  by  diminishing  the  supply  of  blood,  and  thus 
checking  the  over-growth,  which  is  the  essential  feature  of  the 
disease. 

CAXrCER  OF  TH&  SCROTUAX 

(^Chimney -sweep's  Cancer)  is  of  the  epithelial  variety,  and  seems 
to  be  due  to  the  irritation  which  is  caused  by  the  soot  in  consti- 
tutions that  are  predisposed  to  malignant  disease. 

It  begins  as  a  wart  or  tubercle.  In  this  state  it  may  remain 
for  a  long  time.  Presently  it  becomes  red,  and  thinned  on  the 
surf>ice,  bursts,  ulcerates,  and  spreads  rapidly  in  small  warty  ex- 
crescences. If  it  is  allowed  to  remain,  it  gives  rise  to  a  foul  and 
offensive  ulcer,  infects  the  inguinal  and  pelvic  glands,  and  impairs 
the  general  health. 

The  only  effectual  treatment  is  early  and  complete  removal  by 
the  knife,  the  ecraseur,  or  the  galvanic  ecraseur.  Under  any 
circumstances,  the  prognosis  is  far  from  favourable. 


VESZCO-VAGIZTAXi  FISTTTIiA 

means  a  communication  between  the  vagina  and  the  bladder  or 
urethra.  It  is  generally  the  result  of  sloughing,  caused  by  a 
difficult  and  tedious  labour. 

z 


338  DISEASES  OF  TISSUES  AND  OEGANS. 

Treatment. — The  patient  should  keep  herself  scrupulously 
clean,  and  when  she  passes  water  she  should,  if  possible,  lie  on 
her  face,  or  support  herself  upon  her  hands  and  knees.  If  the 
communication  is  very  small,  it  should  be  touched  with  a  wire 
heated  by  a  galvanic  battery.  If  this  is  done  once  a  fortnight,  it 
may  effect  a  cure.  If  the  communication  is  larger,  an  operation 
will  be  necessary.  It  should  be  performed  thus : — The  patient 
should  be  placed  in  the  lithotomy  position,  or  else  made  to  lean 
on  her  knees  and  elbows,  supported  on  pillows.  The  vagina 
should  be  held  open  by  suitable  retractors.  The  surgeon  then 
pares  the  edges  of  the  fissure,  throughout  their  whole  length, 
and  brings  the  raw  surfaces  accurately  together  by  means  of  wire 
sutures.  A  catheter  should  be  kept  in  the  bladder,  so  as  to  pre- 
vent the  accumulation  of  urine.  The  spasmodic  action  of  the 
bladder  and  bowels  should  be  allayed  by  repeated  doses  of  opium. 

RUPTURED  PERXXTEUm. 

The  perineum  is  sometimes  ruptured  during  parturition.  When 
this  happens,  the  rent  should  be  united  immediately.  If  this  is 
not  done,  the  operation  will  have  to  be  delayed  until  the  patient 
is  convalescent,  and  in  the  meantime  she  will  suffer  much  incon- 
venience and  distress.  Sometimes  the  tear  stops  at  the  sphincter 
ani ;  sometimes  it  extends  quite  through  into  the  rectum. 

Treatment. — A  sufficient  number  of  silk,  catgut,  or  wire  stitches 
should  be  introduced  immediately  after  delivery,  and  without 
shifting  the  patient's  position.  If,  however,  this  is  not  done,  or 
if  it  has  been  done  but  without  success,  an  operation  will 
have  to  be  undertaken  at  a  future  time.  It  should  be  performed 
thus: — The  patient  should  be  placed  in  the  lithotomy  posi- 
tion, or  simply  laid  on  her  side  with  the  legs  drawn  up.  The 
edges  of  the  rent  are  then  to  be  thoroughly  pared,  and  brought 
into  accurate  apposition  by  means  of  the  quilled  suture  (see 
Fig.  28).  If  the  operation  is  done  at  once,  it  is  not  necessary  to 
pare  the  edges.  If  the  sphincter  has  been  torn,  its  contractions 
will  be  apt  to  prevent  union.  It  must  therefore  be  divided  on 
each  side  of  the  original  wound.  A  catheter  should  be  kept  in 
the  bladder,  and  opium  given  to  prevent  the  action  of  the 
bowels. 

GOirORRHCBA 

is  the  term  applied  to  a  specific  inflammation  of  the  urethra  or 
vagina,  the  result  of  impure  sexual  intercourse,  and  accompanied 
by  a  purulent  discharge.  After  exposure  to  infection,  an  uncer- 
tain period  elapses  before  the  symptoms  show  themselves.  On 
an  average  it  may  be  set  down  at  four  or  five  days. 


GONOEEHCEA.  339 

The  disease  may  be  divided  into  three  periods — (1)  That  of 
accession  ;  (2)  that  of  acute  inflammation ;  (3)  that  of  decline. 

Symptoms. — {First  stage.) — In  the  male,  the  disease  comes  on 
with  slight  heat  and  irritation  at  the  point  of  the  penis.  The 
glans  becomes  congested,  and  of  a  bright  red  colour,  the  lining 
membrane  of  the  urethra  is  swollen,  and  the  orifice  partly  closed. 
Tliere  is  a  thin,  whitish,  watery  discharge.  The  urine  is  passed 
with  difficulty,  and  the  stream  is  diminished,  twisted,  and  forked. 
These  symptoms  are  accompanied  by  a  good  deal  of  dull,  aching 
pain  in  the  back,  loins,  and  testicles,  and  there  is  more  or  less 
pyrexia. 

(Second  stage.) — Soon  these  symptoms  become  aggravated. 
The  discharge  becomes  thick,  puriform,  and  perhaps  of  a  greenish 
or  reddish  tinge.  There  are  prolonged  and  painful  erections  at 
night.  Sometimes,  during  erection,  the  penis  is  curved,  as  if  it 
were  tied  down  with  a  string  {chordee) — a  state  of  things  which 
is  exquisitely  painful,  and  is  probably  due  to  deposit  of  lymph  in 
the  corpus  spongiosum,  which  interferes  with  the  uniform  expan- 
sion of  the  organ.  Sometimes  the  glans  is  excoriated,  and  emits 
a  purulent  discharge  (balanitis).  Sometimes  the  prepuce  is 
cedematous,  and  perhaps  fixed  in  the  condition  of  phimosis  or 
paraphimosis.  Abscesses  may  form  in  the  substance  of  the  penis, 
and  burst  either  internally  or  externally.  The  lymphatic  glands 
in  the  groin  may  become  inflamed  and  suppurate  {bubo).  Either 
testicle  may  become  acutely  inflamed  (orchitis).  These  are  some 
of  the  complications  which  may  arise  in  the  course  of  a  severe 
case  of  gonorrhoea ;  and  when  the  acute  symptoms  are  on  the 
decline,  there  are  often  rheumatic  pains  of  an  obstinate  kind 
about  the  joints  of  the  extremities  [gonorrJioeal  rheumatism). 

(Third  stage.) — When  the  inflammation  has  run  its  course,  it 
is  very  likely  that  a  thin,  muco-purulent  discharge  (gleet)  may 
remain  for  some  time,  and  prove  very  intractable. 

Inflammation  may,  however,  be  excited  in  the  raucous  mem- 
brane of  the  urethra  by  ordinary  causes — external  violence,  the 
use  of  instruments,  &c.  The  disease  is  then  called  urethritis. 
It  may  run  much  the  same  course  as  gonorrhoea  and  may  re- 
quire much  the  same  treatment  j  but  on  moral  grounds  it  is  im- 
portant to  make  the  [distinction. 

Treatment. — If  the  gonorrhoea  is  in  its  first  stage,  the  patient 
should  be  advised  to  take  a  purge,  to  restrict  his  diet  to  what  is 
plain  and  unstimulating,  to  bathe  the  parts  frequently  with  cold 
water,  and  to  use  a  slightly  astringent  injection  every  three  hours 
or  oftener  (F.  16,  23,  27).  Strong  applications — whether  in 
the  form  of  injections  or  ointments — are  attended  with  great  risk, 
and  ought  not  to  be  used.     A  mild  lotion  injected  at  short  in- 

z2 


340  DISEASES  OF  TISSUES  AND  OEGANS. 

tervals,  as  I  have  recommended  in  the  treatment  of  ophthalmia 
neonatorum,  is  perfectly  safe  and  very  effectual.  Cubebs  or 
copaiba  or  the  oil  of  sandal  wood  may  be  given  at  the  same  time, 
and  these  means  may  have  the  effect  of  cutting  short  the  attack 
(P.  43,  54). 

Mode  of  injecting. — The  patient  should  raise  the  penis  between 
the  forefinger  and  thumb  of  his  left  hand,  holding  it  near  the 
point.  He  should  then  carefully  introduce  the  nozzle  of  a  glass 
syringe  into  the  urethra  for  the  space  of  an  inch  or  so,  and  fix  it 
in  that  position  by  compressing  it  gently  with  his  left  forefinger 
and  thumb.  He  then  slowly  pushes  down  the  piston  with  his 
right  hand.  The  injection  should  be  allowed  to  remain  in  the 
urethra  for  a  few  minutes.  As  soon  as  the  syringe  is  taken  away, 
and  the  left  hand  removed,  the  elasticity  of  the  urethra  will 
expel  the  fluid  that  has  been  thrown  in. 

During  the  second  stage,  the  stage  of  acute  inflammation,  if 
the  symptoms  run  high,  the  treatment  should  be  strictly  anti- 
phlogistic. The  patient  should  keep  the  house,  and  avoid  exercise. 
No  injections  should  be  used,  unless  they  be  of  tepid  water.  The 
parts  should  be  constantly  fomented  with  flannels,  wrung  out  of 
hot  water.  In  milder  cases  it  may  suffice  to  envelope  the  penis 
in  lint  dipped  in  warm  water,  and  covered  with  a  piece  of  oil- 
silk.  The  bowels  should  be  kept  open  by  small  and  repeated 
doses  of  sulphate  of  magnesia — ^  three  times  a  day,  or  a  seidlitz 
powder  every  morning,  while  the  urine  is  diluted,  and  its  acidity 
lessened,  by  alkaline  or  mucilaginous  drinks — soda  water,  or  im- 
perial drink  (E.  103),  or  barley  water,  or  linseed  tea  (F.  102)  to 
which  a  little  nitre  or  carbonate  of  potass  has  been  added.  By 
this  means  the  scalding  pain  in  micturition  will  be  much  reduced. 
Chordee  may  be  relieved  by  a  full  dose  of  Dover^s  powder  at 
bed-time,  or  by  smearing  tbe  penis  with  extract  of  belladonna,  or 
by  a  mixture  of  camphor  and  opium  in  a  pill  or  suppository. 

If  there  is  retention  of  urine,  from  the  swollen  state  of  the 
mucous  lining  of  the  urethra,  fomentations  or  warm  hip-baths 
should  be  assiduously  used,  and  opium  suppositories  introduced 
into  the  rectum  (F.  90).  It  may  even  be  necessary  to  leech  the 
perineum.  If  these  measures  fail,  then,  and  not  till  then,  a  full- 
sized  catheter  should  be  passed  into  the  bladder. 

If  the  lymphatic  glands  in  the  groin  become  inflamed  (bubo), 
they  should  be  treated  by  rest,  fomentations,  and  leeches.  If 
matter  forms,  an  incision  should  be  made  in  a  direction  parallel 
with  Poupart's  ligament. 

When  the  acute  symptoms  have  subsided,  and  the  discharge 
has  become  thin  and  muco-purulent,  we  return  to  the  use  of  mild 
astringent  injections  and  cold  sponging.     If  the  patient's  stomach 


GONOREHCEA.  341 

will  bear  it,  he  should  again  take  cubebs  or  copaiba  or  oil  of 
sandal  wood.  The  bowels  should  be  regulated,  and  the  diet 
must  still  be  restricted ;  all  alcoholic  and  stimulating  drinks  should 
be  forbidden.  The  same  treatment  and  manner  of  life  should  be 
rigidly  pursued  for  a  fortnight  after  the  discharge  has  ceased. 

If  a  tliin  watery  discharge — a  gleet — persists,  it  must  be 
treated  by  varying  the  injections — trying  the  acetate  of  lead,  the 
sulphate  or  chloride  of  zinc,  the  nitrate  of  silver,  alum,  &c.,  either 
in  turn  or  by  combining  them  (F,  23,  25,  26,  27).  At  the  same 
time,  it  is  of  great  importance  to  improve  the  general  health  by 
tonics  and  a  change  of  air.  Sometimes  much  benefit  results  from 
passing  a  full-sized  catheter  every  three  or  four  days. 

If  gonorrhoeal  rhe^imatism  follows  the  attack,  it  should  be 
treated  by  fomentations,  alkalies,  hot-air  baths,  diaphoretics  in 
large  and  repeated  doses,  and  by  applying  blisters,  or  leeches,  in 
the  neighbourhood  of  the  affected  part.  When  the  acute  symp- 
toms have  subsided,  the  iodide  of  potassium  may  be  given  with 
advantage.  A  visit  to  the  thermal  springs  of  Bath,  Buxton,  or 
Aix-la-Chapelle  is  often  of  great  benefit. 

Warts  {condylomata  acuta)  often  follow  gonorrhoea,  particu- 
larly if  the  patient  has  allowed  the  discharge  to  lodge  beneath 
the  foreskin,  or  if  there  has  been  much 
inflammation  of  the  glans  or  prepuce.  ^' 

They  are  generally  situated  along  the 
corona  glandis,  or  on  the  frsenum  (Fig. 
153).  When  they  are  very  numerous, 
and  of  large  size,  they  may  be  mistaken 
for  cancer  of  the  penis.  But  the 
history  of  the  case,  the  softness  of  the 
base,  and  the  fact  that  when  they  are 
removed  a  healthy  mucosa  is  left,  will 
generally  establish  the  diagnosis. 

The  treatment  consists  in   snipping 
them  off  with  scissors,  and  then  touch-         Gonorrhoeal  warts, 
ing   the    bleeding    points    with    lunar 

caustic.  When  they  are  few,  small,  and  scattered,  much  benefit 
may  be  derived  from  the  use  of  a  calomel  ointment  (F.  89),  or 
from  a  lotion  of  corrosive  sublimate. 

Gonorrhoea  in  the  female. — Gonorrhoea  in  women  is  altogether 
a  less  formidable  malady  than  it  is  in  men.  This  arises  from  the 
fact  that  the  parts  concerned  are  comparatively  large  and  simple. 
We  have  not  to  deal  with  a  long,  narrow,  and  complicated  canal 
like  the  male  urethra. 

The  symptoms  of  gonorrhoea  in  women  are  much  the  same  as 
those  which  have  been  already  described ;  only  the  disease  is  less 


342  DISEASES   OF  TISSUES  AND   OEGANS. 

acute,  and  is  more  apt  to  degenerate  into  a  chronic  gleet.  The 
principal  complications  which  may  arise  are  bubo,  and  ulceration 
of  the  neck  of  the  womb. 

When  a  woman  is  affected  with  gonorrhoea,  the  discharge  may 
proceed  either  from  the  external  parts — the  labia,  nymphse,  and 
meatus  urinarius — or  from  the  vagina,  or  from  the  cervix  uteri. 
In  the  latter  case,  it  will  probably  be  associated  with  superficial 
ulceration. 

Gonorrhoea  must  be  carefully  distinguished  from  other  dis- 
charges to  which  women  are  subject :  (1)  from  leucorrhcea  {fluor 
alhus),  a  thick,  white  discharge,  derived  from  the  cervix  uteri  ; 
and  (2)  from  vulvitis,  an  inflammation  of  the  external  parts  of 
generation,  depending  on  ordinary  causes,  as  want  of  cleanliness, 
intestinal  irritation,  &c.  This  is  not  uncommon  among  the  chil- 
dren of  the  poor,  and  is  of  great  importance  in  a  medico-legal 
point  of  view.  Parents  are  apt  to  think  that  their  children  have 
been  abused,  when,  in  truth,  all  they  want  is  a  warm  bath  or  a 
vermifuge. 

Treatment. — Gonorrhoea  in  the  female  must  be  treated  on  the 
same  general  principles  that  guide  us  in  dealing  with  the  disease 
in  the  male.  During  the  acute  stage,  rest  in  bed,  fomentations, 
warm  hip-baths,  low  diet,  purgatives,  and  salines,  are  the 
remedies  most  to  be  relied  on.  Subsequently,  the  vagina  should 
be  syringed  with  astringent  lotions,  composed  of  the  acetate  of 
l^d,  the  nitrate  of  silver,  the  sulphate  of  zinc,  or  alum  (F.  23, 
25,  26,  16,  8).  Women  should  never  use  a  glass  syringe ;  one 
that  is  made  of  metal,  bone,  or  elastic-gum,  is  much  safer. 

If  the  discharge  is  very  intractable,  it  may  be  necessary  to 
examine  the  cervix  uteri  by  means  of  a  speculum ;  and,  if  need 
be,  to  touch  it  with  the  lunar  caustic,  or  to  apply  some  other 
medication,  such  as  the  tincture  of  iron  with  glycerine. 

SYPKIUS 

is  the  name  applied  to  the  more  severe  form  of  the  venereal 
disease,  which  is  usually  attended  with  a  breach  of  surface.  An 
important  division  is  made  according  to  the  nature  of  the  sore 
which  is  present.     Thus,  they  are  divided  into : — 

1.  The  simple,  soft,  non-infecting  sore,  or  local  contagious 
ulcer. 

2.  The  indurated,  infecting,  Hunterian  chancre. 

We  shall  consider  each  of  these  separately.  But  in  doing  so, 
it  will  be  impossible  for  us  to  do  more  than  mention  the  leading 
features  of  each  case.  The  investigation  of  syphilis  is  full  of  in- 
terest. It  is  a  subject  which  has  made,  and  is  still  making,  great 
progress.     Many  theories  have  been  propounded,  many  guesses  at 


SYPHILIS.  343 

the  truth  have  been  made,  but  into  these  we  cannot  here  enter. 
We  must  confine  ourselves  to  a  statement  of  the  most  recent 
views  on  the  subject. 

1.  The  simple,  non'infecting  sore,  or  soft  chancre,  or  local 
contagious  ulcer,  begins  as  a  small,  irritable  pimple.  The  period 
of  incubation  of  the  virus  is  short.  Indeed,  it  is  not  improbable 
that  it  begins  to  work  from  the  moment  of  its  application.  At 
any  rate,  the  pimple  generally  shows  itself  within  forty-eight 
hours.  It  rapidly  runs  on  to  suppuration,  forming  a  pustule. 
This  bursts,  and  gives  rise  to  a  superficial  ulceration.  The  sore 
is  usually  situated  in  the  sulcus  between  the  prepuce  and  the 
glans,  particularly  at  the  sides  of  the  frsenum.  The  base  of  the 
ulcer  is  soft  j  it  can  be  easily  compressed  between  the  fingers ; 
and  the  discharge  from  the  surface  contains  pus  globules,  mixed 
with  the  debris  of  the  tissues.  The  lymphatic  glands  in  the  groin 
soon  become  inflamed,  and  generally  suppurate.  But  in  most 
cases  the  mischief  stops  here.  The  system  does  not  become 
infected,  and  secondary  symptoms  do  not  follow. 

Sometimes,  however,  the  sore  spreads  deeply  and  rapidly,  with 
phagedsenic  action.  Sometimes  it  creeps  over  the  surface  in  the 
form  of  a  serpiginous  ulceration.  Sometimes  a  large  portion  of  the 
tissues,  and  even  the  whole  body  of  the  penis,  sloughs  (sloughing 
phagedsena). 

The  soft  sore  is  frequently  multiple  ;  several  may  be  present  at 
the  same  time.  It  is  auto-inoculable — that  is  to  say,  if  the 
matter  of  the  sore  is  inoculated  on  another  part  of  the  individual 
who  is  afiected  it  will  produce  a  sore  like  the  original  one. 
And  if  the  matter  is  inoculated  on  a  second  person  it  will 
have  the  same  efiect.  As  often  as  these  experiments  are  repeated, 
sores  may  be  produced.  The  disease  is  strictly  local,  and  at  the 
same  time  highly  contagious- 

2.  The  infecting  sore,  the  indurated,  Hunterian,  or  true  syphi- 
litic chancre,  difi'ers  in  many  respects  from  the  foregoing.  It 
begins  as  a  pimple  or  crack.  Around  this,  induration  takes 
place,  the  pimple  bursts,  and  an  open  sore,  with  a  hardened 
base,  is  the  result.  Ulceration  and  suppuration  are  no  essential 
parts  of  the  disease,  though  they  are  usually  present  from  some 
local  cause  of  irritation. 

The  virus  has  a  lengthened  period  of  incubation  (15  to  25  days) 
before  the  sore  is  developed ;  and  then  a  second  and  shorter 
period  (10  or  12  days)  elapses  before  the  induration  is  complete, 
and  the  glands  become  enlarged  and  hardened.  The  sore  is  gene- 
rally single.  The  secretion  is  said  to  contain  no  proper  pus- 
globules.  The  afiection  of  the  glands  is  usually  multiple,  and 
thej  ^i^a'ii  no  tendency  to  suppurate.     The  disease  gradually  per- 


344  DISEASES  OF  TISSUES   AND  OEGANS. 

vades  tbe  whole  srstem,  and  may  often  be  recognised  by  a  similar 
indolent  enlargement  of  the  glands  in  the  axilla,  under  the  occiput 
and  elsewhere.  Secondary  and  tertiary  symptoms  foUow;  to  these 
we  shall  return  presently.  The  sore  is  not  auto-inoculable — at  least, 
after  systemic  infection  has  taken  place.  The  system  is  so  far 
under  the  influence  of  the  virus  that  the  inoculation  produces  no 
effect.  As  a  rule,  the  patient  is  incapable  of  sufleriug  from 
the  same  form  of  the  disease  a  second  time ;  though,  as  Mr.  Gas- 
coy  en  has  shown,  this  rule  is  open  to  exceptions  ("  Med.  Chir. 
Trans.,"  1S75).  The  virus  from  one  individual  cannot  be  inocu- 
lated on  another,  who  is  still  suffering  from  the  effects  of  an  in- 
fecting sore.  The  disease,  though  at  first  local,  soon  becomes 
systemic,  and  then  the  patient  is  proof  against  inoculation. 

Such  are  the  two  varieties  of  specific  sores  which  are  recognised 
by  modem  surgeons.  But,  in  practice,  it  is  very  common  to  meet 
with  mijced  cases,  where  we  can  only  suppose  that  there  has  been 
a  double  inoculation  at  the  same  time ;  or  that  an  inoculation  of 
one  kind  has  been  speedily  followed  by  an  inoculation  of  the  other 
kind.  These  case?  are  so  perplexing,  that  some  distinguished 
surgeons  doubt  altogether  the  doctrine  of  a  "  duahty  of  poisons  ;" 
and  hold  that  all  sores — whether  hard  or  soft — depend  upon 
one  and  the  same  virus,  which  produces  different  effebts,  according 
to  the  constitution  of  the  patient,  the  situation  of  the  sore,  and 
other  accidental  circumstances. 

Treatment  of  soft,  non-infecting  sores. — If  a  case  presents  itself 
where  there  is  a  suspicious-looking  pimple,  which  has  appeared 
within  a  day  or  two  after  an  impure  connection,  it  should  be 
touched  with  strong  nitric  acid,  and  hghtly  dressed.  When  the 
esd^r  separates,  a  healthy  granulating  sore  will  probably  be  left. 
If  the  sore  is  in  a  more  advanced  stage,  or  if  it  is  irritated  and 
infiamed,  this  treatment  is  inapplicable.  If  more  than  a  very 
short  time  has  elapsed  from  the  date  of  the  appearance  of  the 
sore,  it  is  highly  improbable  that  we  shall  succeed  in  preventing 
systemic  infection  in  the  case  of  an  indurated  chancre. 

Supposing  the  sore  is  well  formed  when  it  is  first  seen,  our 
treatment  must  depend  upon  the  characters  which  it  presents. 

If  it  is  a  soft  sore,  irritation  of  every  kind  should  be  avoided, 
while  some  simple  stimulating  lotion  or  ointment  should  be 
applied  (F.  22,  25).  If  the  inguinal  glands  become  inflamed,  they 
must  be  treated  by  rest,  fomeiitations,  and  leeches.  If  suppuration 
takes  place,  an  iucision  must  be  made ;  or,  if  the  patient  shrinks 
from  the  knife,  a  piece  of  potassa  fusa  may  be  pressed  firmly  down 
on  the  summit  of  tbe  bubo.  This  will  produce  a  limited  eschar, 
and  give  vent  to  the  pus. 

If  ulceration  spreads  rapidly  and  deeply  (phagedseua),  the  sur- 


SYPHILIS.  345 

face  mnst  be  destroyed  with  nitric  acid,  and  afterwards  dressed 
with  stimulating  lotions  (F.  13,  27).  At  the  same  time  the  general 
health  must  be  supported  by  tonics  and  a  nutritious  diet. 

If  sloughing  occurs  (sloughing  phagedsena),  poultices  must  be 
applied  until  the  dead  tissues  separate,  and  then  the  raw  surfaces 
should  be  dressed  with  stimulating  lotions.  A  lotion  of  the  tar- 
trate of  iron  forms  an  excellent  application  in  these  cases. 
Powdered  iodoform  has  been  highly  recommended.  If  there  is 
much  constitutional  disturbance,  it  must  be  met  by  aperients, 
salines,  and  opiates. 

Treatment  of  hard  chancres. — If,  on  the  other  hand,  the  sore 
is  a  hard  one,  and  presents  an  indurated  base  at  the  time  it  is  first 
seen,  the  treatment  must  be  different.  In  a  case  of  this  kind 
some  surgeons  think  it  best  to  heal  the  local  sore  5  and,  when 
secondai'y  symptoms  follow,  to  deal  with  them  as  they  arise. 
Others  endeavour  to  eliminate  the  poison  from  the  system  at 
once,  so  as  to  prevent  the  occurrence  of  secondaries. 

And  here  we  are  met  by  an  import^mt  question — Should  mer- 
cury be  used  or  not  ?  Has  it  any  specific  influence  over  the 
syphilitic  poison  ? 

These  are  questions  upon  which  the  most  opposite  opinions 
have  been  entertained.  That  mercury  has  some  specific  influence 
over  the  poison  of  syphilis  seems  clear  from  the  rapid  and  com- 
plete cure  which  it  effects  in  cases  of  infantile  syphilis.  On  the 
other  hand,  there  can  be  no  doubt  that  by  far  the  greater  num- 
ber of  chancres  will  heal  without  mercury ;  that  it  is  a  medicine 
which  is  capable  of  doing  great  mischief;  that  it  must  be  given 
with  caution,  and  that  it  should  never  be  pushed  to  extremes. 
Mr.  Hutchinson,  whose  opinion  upon  this  subject  deserves  great 
weight,  regards  mercury  as  quite  an  antidote  to  tbe  poison  of 
syphilis.  His  rule  is  : — "  Begin  early,  continue  long,  do  not 
salivate." 

Mercury  may  always  be  employed  locally,  provided  the  sore  is 
not  in  an  inflamed  or  irritable  state,  in  the  form  of  blue  oint- 
ment, or  of  the  black  or  yellow  wash. 

If  the  patient  is  broken  in  health  from  dissipation,  if  he  is  en- 
feebled by  privation  or  disease,  if  he  is  of  a  strumous  or  cachectic 
habit  of  body,  mercury  should  either  be  withheld  altogether,  or 
given  with  great  caution,  lest  its  depressing  effect  should  aggra- 
vate the  malady. 

If  there  is  no  objection  to  its  use,  it  may  be  administered  either 
by  t\\Q  mouth,  or  by  inunction,  or  hy  fumigation. 

If  we  desire  to  bring  the  patient  rapidly  under  the  influence  of 
mercury,  the  best  preparations  are  the  blue  pill,  or  calomel  in 
combination  with  opium  (F.  82).     If  our  aim   is  to  produce  a 


S46  DISEASES  OF  TISSUES  AND   ORGANS. 

slight  but  continued  effect,  it  will  be  better  to  give  Plummer's 
pill,  or  grey  powder,  or  the  corrosive  sublimate  (P.  50).  These 
are  the  preparations  which  are  most  suitable  for  internal  use. 

Sometimes  mercury  given  by  the  mouth  irritates  the  stomach, 
and  purges  the  patient.  When  this  is  the  case,  it  may  be  em- 
ployed as  an  inunction.  A  drachm  of  blue  ointment  may  be 
rubbed  into  the  armpits,  or  into  the  inside  of  the  thighs,  twice  a 
day ;  or  the  same  quantity  may  be  spread  on  a  roll  of  lint,  and 
worn  round  the  leg,  or  round  the  waist.  This  is  the  best  way  of 
administering  mercury  to  infants. 

Mercury  may  be  used  as  a  fumigation,  by  causing  the  patient 
to  undress,  and  sit  upon  a  cane-bottomed  chair,  beneath  which 
ten  grains  of  calomel  are  volatilized  over  a  spirit-lamp,  or  upon 
a  hot  brick.  A  blanket  should  be  thrown  over  both  the  patient 
and  the  chair,  and  as  soon  as  all  the  mercury  has  disappeared,  he 
should  wrap  himself  in  the  blanket  and  step  into  bed. 

When  mercury  produces  its  characteristic  effects  upon  the  con- 
stitution, the  gums  become  red  and  spongy,  the  tongue  swells, 
the  sublingual  glands  become  enlarged,  and  there  is  a  profuse 
flow  of  saliva  from  the  mouth.  At  the  same  time  the  breath 
exhales  a  heavy,  sweetish,  and  very  characteristic  odour.  When 
mercury  is  pushed  to  an  extreme,  and  salivation  is  kept  up  for  a 
length  of  time,  ulceration  of  the  mouth  and  necrosis  of  the 
bones  are  apt  to  follow ;  but  cases  in  which  these  untoward 
results  have  been  brought  about  are  very  rarely  seen  at  the 
present  day. 

If  we  desire  to  bring  the  system  under  the  influence  of  mer- 
cury, we  should  content  ourselves  with  keeping  up  a  slight 
action  on  the  gums.  It  is  seldom  or  never  necessary  to  go  farther 
than  this. 

The  iodide  is  a  very  useful  preparation  of  mercury.  It  seems 
to  combine  the  specific  effect  of  both  the  iodine  and  the  mercury 
(F.  49). 

While  a  patient  is  taking  mercury  he  should  live  well;  he 
should  have  plenty  of  plain  nutritious  food,  and  wear  a  sufficiency 
of  warm  clothing. 

BUSO 

is  the  term  applied  to  enlargement  or  inflammation  of  the  lym- 
phatic glands  which  lie  above  Poupart's  ligament,  consequent 
upon  venereal  disease.  We  have  already  seen  that  it  is  a  frequent 
complication  of  gonorrhea,  but  it  is  also  met  with  in  both  the 
varieties  of  syphilis. 

A  bubo  that  is  due  to  gonorrhoea,  or  to  the  irritation  of  a  soft 
venereal  sore,  is  acutely  inflamed,  and  very  prone  to  run  on  to 


BUBO.  347 

suppuration.  The  irritation  may  manifest  itself  in  one  groin  or 
in  both.  One  lymphatic  gland  alone  may  be  affected,  or  several ; 
and  when  suppuration  takes  place,  the  pus  may  burrow  underneath 
the  skin  from  one  to  the  other. 

The  multiple  and  indolent  enlargement  of  the  same  glands, 
which  is  so  characteristic  of  an  infecting  sore,  has  been  described 
already. 

Treatment. — The  treatment  of  the  indolent  buboes  which  result 
from  a  Hunterian  chancre  is  constitutional  rather  than  local. 
But  when  the  glands  are  acutely  inflamed  the  surgeon  should 
endeavour  to  prevent  them  from  suppurating.  With  this  view  the 
patient  should  be  directed  to  abstain  from  walking  and  to  give 
himself  as  much  rest  as  possible ;  at  the  same  time  evaporating  or 
discutient  lotions  (F.  18,  21)  should  be  constantly  applied.  If  sup- 
puration takes  place,  the  abscess  should  be  opened  by  an  oblique 
incision,  parallel  to  Poupart's  ligament,  and  poultices  or  water- 
dressings  applied.  If  burrowing  takes  place,  the  sinuses  ought  to 
be  laid  open,  and  healed  from  the  bottom.  When  cicatrization  has 
occurred,  and  nothing  remains  but  an  indurated  state  of  the  tissues, 
even  pressure  by  means  of  a  pad  and  bandage  is  of  great  service. 

In  keeping  dressings  upon  the  groin,  as  well  as  in  exerting 
pressure  and   in  various  other   cases,    the  spica  or    figure-of-8 
bandage    for    the   groin    is   of 
great  use.     We  shall  therefore  ^^* 

take   this   opportunity   of    ex- 
plaining it. 

Figure-of-^  handage  for  the 
groin. — This  bandage  is  fre- 
quently spoken  of  as  the  spica, 
from  some  fancied  resemblance 
which  it  is  supposed  to  bear  to  p^^^^^^  ^^  3  .^^  bandages, 
the  arrangement  of  the  grains 

in  an  ear  of  corn.  But  as  the  word  spica  conveys  no  distinct 
meaning,  we  have  thought  better  to  call  it,  what  it  really  is, 
a  figure-of-8  bandage  for  the  groin. 

The  bandage  may  be  applied  either  to  one  groin  or  to  both. 
When  it  is  applied  only  to  one  side  it  is  called  a  single  figure-of.8 
for  the  groin  (single  spica.  Fig.  154,  a) ;  when  to  both  sides,  a 
double  figure-of-8  for  the  groin  (double  spica.  Fig.  154,  h). 

To  apply  the  single  figure-of-8  to  the  groin  the  surgeon  lays 
the  end  of  the  roller  on  the  inside  of  the  thigh  of  the  affected 
side,  and  conducts  the  roller  once  round  in  a  circular  form  so  as 
to  fix  the  end  of  the  bandage.  He  then  brings  the  roller  up  the 
inside  of  the  thigh  and  along  the  fold  of  the  groin,  taking  care  to 
adjust  any  pads,  dressings,  &c.,  that  it  is  intended  to  retain. 


348 


DISEASES   OF  TISSUES  AND   ORGANS. 


Single  spica  bandage. 


Then  he  carries  it  on,  round  the  back  of  the  pelvis  to  the  opposite 
side,  and  obliquely  across  the  abdomen,  over  the  pubes,  to  the 
outside  of  the  thigh  on  the  affected  side,  and  then  continuing  it 

under  the  thigh  he  completes 
the  first  figure-of-8 — one  loop 
of  the  8  embracing  the  pelvis, 
while  the  other  surrounds  the 
thigh  (Fig.  155).  The  same 
steps  may  then  be  repeated  as 
often  as  they  are  necessary. 

In  applying  the  double 
figure-of-8  to  the  groins  the 
surgeon  begins  precisely  as  in 
the  foregoing  case,  but  after 
be  has  completed  one  figure- 
of-8  and  has  carried  the 
bandage  for  the  second  time 
round  the  back  of  the  pelvis, 
he  brings  it  down  along  the  opposite  groin  to  the  inner  side 
of  the  corresponding  thigh.  He  then  conducts  it  round  the  back 
of  the  thigh  to  its  outer  side,  and  then  obliquely  upwards  across 
the  pubes  and  abdomen  to  the  other  side  of  the  pelvis,  in  this 
way  completing  the  second  figure-of-8«  These  steps  may  be 
repeated  as  often  as  they  are  necessary,  the  upper  loop  of  the  8  in 
each  case  surrounding  the  pelvis,  while  <^be  lower  one  embraces 

the  right  and  left  thighs 
alternately  (Fig.  156). 
It  is  important  to  ob- 
serve that  the  turns 
round  the  body  should 
fall  just  below  the  brim 
of  the  pelvis. 

In  commencing  this 
bandage  the  surgeou 
may,  if  he  pleases,  begin 
by  taking  a  turn  round 
the  pelvis,  instead  of 
round  the  thigh,  in 
order  to  get  a  fixed  point 
from  which  to  start. 
A  simpler  method  of  retaining  dressings  in  this  situation  is  by 
means  of  the  triangular  bandage  for  the  groin.  It  consists  of  a 
waistband  to  which  is  stitched  a  triangular  piece  of  calico,  and 
to  the  lower  end  of  the  triangle  is  fastened  a  strip  of  narrow 
roller.     Wlien  it  is  applied,  the  waistband  is  secured,  the  trian- 


Double  spica  bandage. 


SECONDARY  SYPHILIS. 


349 


gular  piece  of  calico  is  adjusted  over  the  affected  part,  and  the 
lower  corner,  with  its  strip  of  bandage  attached,  is  carried  under 
the  perineum,  and  fastened  to  the  waistband  at  the  patient's  side 
(see  Fig.  50,  b). 

SECONDARV  SVPHIXiIS. 

When  the  poison  of  syphihs  has  infected  the  constitution,  it 
produces  certain  secondary  symptoms.  These  symptoms  show 
themselves  at  a  variable  period,  from  two  weeks  to  six  months  or 
more,  after  the  primary  disease.  First  of  all,  the  skin,  and  the 
mucous  membranes  become  affected  (secondary  symptoms),  after- 
wards the  bones  and  internal  organs  {tertiary  symptoms). 

Constitntional  syphilis  sometimes  leads  directly  to  a  fatal 
result  by  affecting  the  brain,  the  liver,  or  some  other  vital  organ. 
In  any  case  it  is  extremely  diflBcult  to  eradicate,  and  it  often 
modifies  the  patient's  constitution  for  the  remainder  of  his  life. 
It  is  worthy  of  special  notice  that  the  normal  secretions  of  persons 
having  secondary  syphilis — e.g.,  the  semen,  the  saliva,  or  the  milk 
— as  well  as  the  discharges 

from    secondary    sores,    can  Fig.  157. 

communicate  the  disease. 
But  when  the  later  stages 
have  been  reached,  the  poison 
seems  more  localised,  and  is 
less  prone  to  be  eliminated 
from  the  blood. 

The  syphilitic  eruptions 
on  the  sl'iii  (syphilides)  may 
take  almost  any  form,  cor- 
responding pretty  nearly 
to  the  ordinary  cutaneous 
diseases.  But  they  are  all 
characterised  by  their  dull, 
copper  colour;  by  the  fact 
that  they  do  not  itch;  by 
their  circular  shape  and 
grouping ;  and  by  the 
brownish  stains  or  dis- 
colourations  which  the 
severer  forms  leave  behind 

them.  Fig.  157  represents  a  remarkable  case  of  syphilitic  rupia 
in  a  young  man  who  was  in  Charing  Cross  Hospital  under  the 
care  of  Dr.  Silver. 

It  would  be  impossible  for  us  to  find  space  for  even  a  short 
description  of  each  of  the  syphilitic  affections  of  the  skin,  but  we 


7;/     ^      Ai; 

Syphilitic  rupia  on  the  face. 


350 


DISEASES  OF  TISSUES  AND  ORGANS. 


may  take  this  opportunity  of  mentioning  that  they  have  heen 
regarded  by  Mr.  Hutchinson  and  others  as  analogous  to  the 
rashes  of  the  exanthematous  diseases.  Indeed,  syphilis  may 
well  be  regarded  as  an  exanthem  whose  march  is  very  slow,  and 
whose  stages  are  very  long. 

Mucous  tubercles  {condylomata  lata)  are  a  peculiar  development 
of  the  skin,  which  is  apt  to  occur  near  the  orifices  of  the  mucous 
canals,  especially  where  the  parts  are  bathed  in  perspiration,  and 
where  irritation  is  kept  up  by  the  movement  of  two  contiguous 
surfaces :  hence  they  are  commonest  around  the  anus  and  vulva. 
They  form  small,  soft,  flattened  tumours,  and  secrete  a  thin, 
offensive  discharge,  which  is  probably  contagious.  I  have  also 
seen  them  on  the  under  surface  of  the  tongue. 

Treatment. — They  should  be  kept  very  clean,  and  rubbed 
with  calomel  ointment  (F.  89),  or  dusted  over  with  the  dry 

calomel,  or  bathed  with  a 
Fig.  158.  „^^^        mercurial  wash. 

Syphilitic  ulcerations. — 
Secondary  syphilis  is  par- 
ticularly prone  to  manifest 
itself  in  the  mucous  mem- 
brane of  the  pharynx.  The 
patient  complains  of  sore 
throat.  The  affection  may 
consist  of  a  mere  conges- 
tion and  excoriation  of  the 
mucous  membrane  of  the 
fauces  or  tonsils,  or  it  may 
present  a  foul,  excavated 
ulcer,  with  ragged  edges, 
and  covered  with  a  greyish 
yellow  slough. 

We  often  see  syphilitic 
ulcers  on  the  legs.  They 
begin  in  small  gummy 
tumours  in  the  subcuta- 
neous areolar  tissue,  soften, 
break,  and  form  a  deep 
ulcei',  which  is  characterised 
by  its  circular  form,  its  clean-cut  edges,  its  irregular  base,  and  un- 
healthy discharge  (Fig.  158).  Such  ulcers  are  often  multiple, 
and  one  of  their  favourite  situations  is  the  neighbourhood  of  the 
knee ;  so  much  so  that  it  may  be  laid  down  as  a  general  rule  that 
sores  on  the  leg  about,  or  above,  the  knee-joint  have  usually  a 
syphilitic  origin. 


SyphiUtic  sores  on  the  leg. 


SECONDARY  SYPHILIS. 


351 


Fig.  159. 


Superficial  ulceration  between  the  fingers,  such  as  that  which 
is  represented  in  Fig.  159,  or  between  the  toes  (Fig.  160),  is  very 
characteristic  of  secondary  syphilis. 

The  inside  of  the  mouth,  the 
lips,  the  tongue,  and  even  the 
larynx,  are  liable  to  be  affected  by 
syphilitic  ulceration.  Cracks  and 
fissures  form  at  the  angles  of  the 
mouth,  and  along  the  sides  of  the 
tongue.  Whitish  or  yellowish 
spots  appear  on  the  gums  and 
lining  membrane  of  the  cheeks. 
The  mucous  covering  of  the  larynx 
is  apt  to  become  thickened  and 
ulcerated,  leading  to  impairment  of 
the  voice,  and  even  to  suffocation. 

Treatment. — In  all  these  ulcera- 
tive affections,  the  treatment 
must  be  much  the  same.  Cracks  and  fissures  should  be  thoroughly 
touched  with  a  pencil  of  lunar  caustic ;  or,  if  the  ulcerating  sur- 
face is  more  extensive,  it  may  be  brushed  over  w^ith  a  strong 
solution  of  nitrate  of  silver  (forty  grains  to  the  ounce  of  distilled 
water).  If  the  throat  is  in  a  sloughing  and  unhealthy  state, 
the  patient  should  use  a  chlorinated  gargle,  and  the  nitrate  of 
silver  may  be  more  freely  applied.  Fumigating  the  fauces  with 
calomel,  directed  to  the  diseased  spot  by  means  of  a  funnel,  is 
The  ulceration  between  the  fingers  and 
a    mercurial  ointment  or  wash,   and 


Supeificial  ulceration  of  the 
fingers  (syphilitic). 


Fi^.  160. 


often  of  great  benefit, 
toes  is  best  treated  by 
full  doses  of  "  Dono- 
van's solution."  At 
the  same  time,  the 
constitutional  treat- 
ment must  not  be 
overlooked.  The  pa- 
tient should  live  well, 
and,  if  possible,  he 
should  have  a  dry, 
mild,  bracing  air. 
During  the  winter  and 
spring  most  parts  of 
England  are  too  cold, 
damp,  and  relaxing.  Thus  a  sea  voyage,  or  a  residence  at  St. 
Leonards,  Bournemouth,  Malaga,  Mentone,  or  some  similar  place 
may  often  be  recommended  with  great  advantage.  If  the  patient 
is  in  pretty  good  general  health,  and  has  not  already  been  treated 


Superficial  ulceration  of  the  toes 
(syphilitic). 


352 


DISEASES   OF  TISSUES   AND  ORGANS. 


Fig.  161. 


with  mercury,  a  mild  course  may  be  prescribed.  If,  however,  his 
health  is  broken,  or  he  has  been  already  salivated,  then  the 
iodide  of  potassium  should  be  given,  in  combination  with  iron 
and  tonics  (F.  60,  62). 

In  syphilitic  ulceration  of  the  larynx,  the  constitutional  treat- 
ment is  of  the  greater  importance,  because  topical  applications 
are  attended  with  difficulty,  If  the  disease  spreads,  and  suffoca- 
tion is  imminent,  it  will  be  necessary  to  perform  tracheotomy. 

Syphilitic  affections  of  the  hones  are  among  the  later,  or 
tertiary,  symptoms  of  the  disease.     The  bones  which  are  most 

frequently  affected  in  constitutional 
syphilis  are  the  tibia,  the  bones  of 
the  skull,  the  clavicle,  and  the  ulna. 
A  slow  inflammation  takes  place  in 
the  bone,  or  in  the  periosteum  cover- 
ing it.  The  affected  spot  is  ex- 
quisitely tender  ;  there  is  great  pain, 
which  is  aggravated  at  night.  Ey 
degrees,  an  oval  swelling,  a  node, 
forms,  which  has  at  first  a  doughy 
feeling,  but  which  afterwards  be- 
comes distinctly  fluctuating.  This 
gradually  involves  the  skin,  and 
bursts,  exposing  the  ulcerated  bone 
beneath.  Fig.  161  was  drawn  from 
a  young  woman,  who  was  in 
Charing  Cross  Hospital  under  the 
care  of  Mr.  Canton.  The  circular 
shape  of  the  sore  and  the  exposed  bone  are  well  seen. 

If  the  disease  is  situated  on  the  skull,  it  may  give  rise  to 
irritation  ef  the  membranes,  and  death  by  meningitis.  Or  it  may 
furnish  an  opening  through  which  the  brain  may  protrude,  or 
there  may  be  internal  nodes  as  well  as  external  j  and  then  the 
cerebral  functions  may  be  very  seriously  impaired. 

Treatment. — The  great  remedy  for  syphilitic  affections  of  the 
bones  is  iodide  of  potassium.  It  should  be  given  in  combination 
with  tonics — the  tartrate,  or  the  ammonia-citrate  of  iron,  for 
example  (F.  60,  62) ;  and  the  patient  should  have  plenty  of  plain, 
nutritious  food,  for  unless  he  has  a  certain  amount  of  vis  vitce  he 
cannot  resist  the  violence  of  the  disease.  Some  patients  are  very 
sensitive  to  the  influence  of  iodide  of  potassium.  I  have  seen  a 
young  man  quite  prostrated  with  severe  headache  and  coryza 
after  taking  two  5-grain  doses,  and  I  have  seen  large  patches  of 
an  erythematous  eruption  on  a  middle-aged  man  who  had  only 
taken  three  5-grain  doses.     The  local  pain  must  be  relieved  by 


Syphilitic  sore  on  forehead. 


INFANTILE  SYPHILIS.  353 

blisters,  or  leeches ;  and  opiates  may  be  given  at  bed-time.  If 
suppuration  has  taken  place,  a  small  valvular  incision  should  be 
made,  and  the  matter  evacuated. 

XM-FAITTIIiE  STPHZXiZS. 

If  either  of  the  parents  are  syphilitic,  the  infant  may  inherit 
the  disease.  If  the  father  is  syphilitic,  he  may  transmit  the 
disease  directly  to  the  foetus  at  the  time  of  conception,  and  the 
mother  may  be  infected  through  her  offspring  ;  or  he  may  com- 
municate it  to  the  mother,  and  she  may  infect  the  child  ;  or  if 
the  mother  alone  is  syphilitic,  the  foetus  may  become  affected 
during  intra-uterine  life,  through  the  maternal  blood. 

When  the  foetus  is  infected  in  any  of  these  ways,  it  is  apt  to 
die  about  the  fourth  month,  and  the  mother  miscarries.  Re- 
peated miscarriages  at  once  suggest  a  syphilitic  taint. 

But  the  case  may  not  be  so  bad  as  this.  The  child  may  be 
born  alive,  but  thin  and  shrivelled,  with  a  prematurely  old  ex- 
pression, a  hoarse  voice,  a  snuffling  breathing,  a  discharge  from 
the  nose,  and  an  eruption  about  the*anus  and  genitals. 

Or,  again,  the  child  may  be  born  apparently  healthy,  and  the 
syphilitic  symptoms  may  show  themselves  a  month  or  six  weeks 
afterwards. 

Treatment. — The  infant  should  be  brought  up  by  hand,  that 
it  may  neither  imbibe  further  poison  from  its  mother,  nor  infect 
a  hired  nurse.  Having  secured  this  point,  the  surgeon  should 
prescribe  mercury,  either  in  the  form  of  small  doses  of  grey 
powder,  or  as  an  inunction  in  the  way  recommended  by  Brodie. 
A  drachm  of  blue  ointment  should  be  spread  upon  a  roll  of  lint 
or  flannel,  and  tied  round  the  child's  thigh  or  waist.  The  appli- 
cation should  be  renewed  every  morning  until  the  symptoms  have 
disappeai'ed. 

Though  the  commonest  manifestations  of  infantile  syphilis  are 
of  a  superficial  kind — snuffles,  cutaneous  eruptions,  mucous 
tubercles,  and  the  like — it  sometimes  happens  that  the  liver,  the 
brain,  and  other  internal  organs  are  affected  by  tumours  which 
are  due  to  the  same  cause.  In  these  cases  the  child  gradually 
wastes  away,  or  else  it  is  attacked  by  convulsions,  and  dies  after  a 
short  illness. 

When  the  surgeon  is  required  to  treat  a  case  of  infantile 
syphilis,  he  ought  not  to  overlook  the  condition  of  the  parents,  for 
by  persuading  them  to  submit  to  timely  treatment  their  future 
offspring  may  be  more  healthy.  He  should  therefore  put  them 
upon  a  mild  course  of  mercury,  or  prescribe  iodide  of  potassium, 
or  such  other  remedies  as  he  may  think  fit,  according  to  the 
state  of  their  health,  and  the  special  symptoms  that  they  present. 

A  A 


354  DISEASES  OF  TISSUES  AND  OEGANS. 

It  is  of  tbe  utmost  importance,  as  Sir  James  Paget  has  pointed 
out,  that  students  should  learn,  by  wide  observation  and  extensive 
practice,  to  recognise  all  the  characters  of  syphilitic  diseases  so 
thoroughly  as  not  to  require  the  help  of  any  statements  from  the 
patients  themselves.  For  many  patients  are  unvpilling,  and  those 
that  would  be  willing  are  often  unable,  to  tell  the  truth  in  these 
cases.  Women  in  the  middle  and  higher  ranks  of  society,  when 
they  have  syphilis,  are  generally  ignorant  of  the  fact,  and  must  be 
allowed  to  remain  without  even  such  a  suspicion  as  would  be  sug- 
gested by  their  being  asked  about  it.  In  such  a  case  a  question 
thoughtlessly  put  might  disturb  the  peace  of  a  family ;  and  no 
benefit  which  the  surgeon  might  hope  to  obtain  from  the  informa- 
tion thus  elicited  could  counterbalance  the  social  mischief  that  it 
might  occasion. 

The  surgeon  is  often  asked  how  soon  it  is  safe  for  a  person  who 
has  had  constitutional  syphilis  to  contract  marriage.  Upon  this 
point  his  answer  should  be  given  with  caution,  because  it  is  doubt- 
ful if  the  syphilitic  taint  can  ever  be  eradicated.  If  the  patient 
falls  into  bad  health  or  destitute  circumstances,  it  may  make  its 
appearance  after  the  lapse  of  many  years  during  which  it  has  lain 
dormant,  and  the  patient  has  been  apparently  in  exaellent  health. 
And,  of  course,  if  the  disease  is  liable  thus  to  revive,  the  patient's 
wife  and  offspring  may  become  infected.  It  is,  therefore,  impos- 
sible to  lay  down  positive  rules, but,  speaking  generally,  the  patient 
should  be  advised  to  wait  till  the  expiration  of  a  year  from  the  time 
when  all  secondary  manifestations  disappeared,  and  in  the  mean- 
while to  take  a  course  of  warm  sulphur  baths.  If  he  can  go  to  a 
warm  climate,  or  take  warm  baths  at  some  of  the  natural  mineral 
springs — Harrogate,  Bath,  Spa,  or  Bareges,  for  example — that  is 
the  best  measure  to  recommend.  Formerly  it  was  the  custom 
to  prescribe  sudoritics,  but  the  course  I  have  indicated  is  safer, 
and  will  probably  be  also  more  agreeable  to  the  patient. 

ONVCHZA. 

Onychia  is  a  disease  of  the  matrix  of  the  nail,  attended  by  in- 
flammation and  ulceration  of  the  adjacent  parts.  It  occurs  under 
two  forms,  (1)  the  simple,  and  (2)  the  malignant  or  specific. 

1.  Simple  onychia  begins  as  a  circumscribed  inflammation  in  the 
root  of  the  nail.  It  is  often  excited  by  slight  injuries — a  prick, 
or  a  pinch,  for  example — in  persons  who  are  out  of  health. 

The  affected  spot  is  red,  hot,  swollen,  and  painful.  Pus  soon 
forms  and  makes  its  way  to  the  surface.  The  nail  becomes  loose, 
shrivelled,  and  black ;  gradually  it  is  thrown  off  and  a  new  one 
grows  in  its  place.  The  new  one  is  often  rough,  and  somewhat 
irregular  in  shape. 


ONYCHIA. 


355 


Fie:.  162. 


Treatment.— The  hand  should  be  well  supported  in  a  sling,  so 
as  to  be  raised  almost  to  the  opposite  shoulder.  The  inflamma- 
tion must  be  met  by  poultices.  If  the  pus  is  confined,  it  should 
be  let  out  by  a  puncture.  Care  must  be  taken  to  protect  the 
young  nail ;  and  of  course  everything  should  be  done  to  regulate 
and  improve  the  patient's  general  health. 

2.  Malignant  onychia  commences  in  the  same  way  as  the  simple 
variety,  but  it  runs  on  to  ulceration,  and  this  ulceration  is  usually 
of  a  most  intractable  kind.  The 
inflamed  spot  has  a  dark,  livid 
colour,  and  breaks  down  into  an 
ofi'ensive  sore.  There  is  a  dis- 
charge of  sanious  pus.  After 
a  while  large  flabby  granulations 
spring  up,  and  the  end  of  the 
finger,  or  toe,  becomes  much 
enlarged  and  clubbed.  The  nail 
turns  black,  shrivels,  and  breaks 
oS  in  pieces ;  and  any  attempt 
which  Nature  makes  to  form  a 
new  one  is  very  imperfect  (Fig. 
162).  This  variety  of  the  disease 
is  often  associated  with  a  ca- 
chectic, strumous,  or  syphilitic 
state  of  the  system. 

Treatment. — Locally,  the  first 
thing    to  be  done  is  to  remove 

the  nail,  which  acts  as  a  foreign  body,  and  keeps  up  irritation. 
The  ulcer  must  then  be  freely  touched  with  lunar  caustic,  and 
dressed  with  stimulating  applications.  Powdered  iodoform  is 
sometimes  very  beneficial.  If  there  is  a  syphilitic  history,  a 
mercurial  ointment  or  the  black  wash  will  be  found  useful. 

Mr.  MacCormac  has  drawn  attention  to  the  use  of  the  pow- 
dered nitrate  of  lead,  which  has  been  employed  with  success  by 
some  Continental  surgeons  as  a  local  application.  I  have  used  it 
in  several  cases,  and  have  been  pleased  by  the  result.  It  cer- 
tainly deserves  a  further  trial,  for  the  disease  is  one  which  is  very 
intractable  under  the  ordinary  treatment. 

Constitutionally,  we  must  endeavour  to  improve  the  patient's 
health  by  tonics,  particularly  cod-liver  oil  and  the  preparations 
of  iron  and  quinine  (F.  41,  55,  56),  by  change  of  air,  and  a  well- 
regulated  manner  of  life.  If  the  case  has  a  syphilitic  origin, 
Donovan's  solution,  the  iodide  of  potassium,  or  the  preparations 
of  mercury,  in  combination  with  tonics,  will  be  most  beneficial 
(F.  50,  52,  43,  44). 

A  a2 


Malignant  onychia. 


356 


DISEASES  OF  TISSUES  AND   ORGANS. 


VIiCEBATIOIO'  OF  THE  GREAT  TOE. 

There  is  a  painful  affection  of  the  great  toe  in  which  the  nail 
is  popularly  said  to  "  grow  into  the  flesh."  It  is  g^enerally  the 
consequence  of  wearing  tight  boots.  The  truth  is,  not  that  the 
nail  grows  into  the  flesh,  but  that  it  is  pressed  against  the  skin, 
thus  keeping  up  a  chronic  irritation  and  inflammation.  The 
tissues  at  the  side  of  the  nail  become  swollen  and  very  tender, 
then  ulceration  takes  place,  and  a  sore  is  established,  which  dis- 
charges a  thin,  sanious  pus.  Large  granulations  spring  up, 
which  are  exquisitely  painful,  and  which  overlap  the  nail,  making 
it  appear  as  if  it  grew  into  the  flesh. 

Treatment. — Tight  boots,  especially  those  which  are  narrow 
across  the  toes,  must  be  laid  aside  altogether,  and  for  a  time  the 
patient  must  wear  only  a  loose  slipper.  The  inflammation  may 
be  partially  subdued  by  poultices  or  cold  lotions,  but  to  effect  a 
radical  cure  more  will  be  necessary.  The  simplest  method  of  pro- 
ceeding is  to  scrape  down  the  nail  until  it  is  thin  and  phable,  touch 
the  ulcerated  surface  with  a  fine  pencil  of  lunar  caustic,  and  then 
introduce  cotton- wool  between  them,  or  a  fold  of  lint  soaked  in  glyce- 
rine, or  in  liquor  potassse,  or  in  a  solution  of  sulphate  of  copper. 
Another  method  is  to  take  a  strip  of  very  thin  sheet-tin  or  of 
gutta-percha,  fold  it  in  the  middle, 
and  introduce  this  fold  between  the 
nail  and  the  skin,  and  then  to 
double  one  side  back  over  the  toes, 
and  the  other  over  the  granulations. 
If  these  or  other  similar  methods 
are  carefully  carried  out  from  day 
to  day,  much  may  be  done  to  relieve 
the  patient,  and  in  some  of  the 
slighter  cases  a  cure  may  be  eff'ected. 
But  if  the  disease  is  severe,  and 
of  long  standing,  a  portion  of  the 
nail  may  have  to  be  removed.  This 
is  a  trivial,  but  a  very  painful  opera- 
tion ;  and  the  patient  should  either 
be  anaesthetised,  or  the  toe  benumbed 
with  ether  spray.  The  sharp  point 
of  a  strong  pair  of  scissors  should 
then  be  passed  underneath  the  nail 
as  far  as  the  matrix,  and  the  nail 
divided  longitudinally.  The  slip  thus  separated  must  then  be 
seized  with  a  forceps,  and  drawn  out  by  the  root. 


Fig.  163. 


Ulceration  of 
great  toe. 


CLUB-FOOT. 


357 


A  simpler  and  less  painful  operation  is  to  cut  off  the  whole  of 
the  granulations,  togetlier  with  a  portion  of  the  adjacent  skin,  by 
a  single  stroke  of  a  scalpel.  The  case  from  which  Fig.  163  was 
taken  was  treated  in  this  way.  The  patient  experienced  imme- 
diate relief,  and  the  wound  healed  favourably  in  a  few  days. 
When  this  last  method  is  adopted,  there  is  but  little  chance  of 
the  disease  recurring,  for  the  contraction  of  the  cicatrix  tends  to 
draw  the  skin  away  from  the  nail. 

COXTRACTIOX  OF  THE  FZUG-ERS. 

The  fingers  not  unfrequently  become  contracted,  and  drawn 
down  towards  the  palm.  The  little  finger  is  generally  the  first 
to  be  affected  in  this  way,  the 
disease  gradually  extending 
to  the  others.  The  process 
of  contraction  is  a  very  slow 
one,  but  the  fingers  become 
so  fixed  that  no  ordinary 
force  can  extend  them. 

The  deformity  seems  to 
depend  upon  a  chronic  in- 
flammation of  the  palmar 
fascia.  Sometimes  this  ap- 
pears to  be  excited  by  the 
constant  and  forcible  use 
of  the  palm,  as  in  handlhig 


Fiff.  164. 


Fingers  contracted  by  gout. 


certain  tools.  At  other  times  it  has  a  constitutional  origin,  and 
is  connected  with  a  rheumatic  or  gouty  tendency.  Fig.  164 
represents  a  striking  example  of  a  hand  distorted  by  gout. 

The  treatment  consists  in  endeavouring  to  overcome  the  con- 
traction by  gradual  extension  by  means  of  a  splint  and  elastic 
bandages.  If  this  is  impracticable,  or  if  the  patient  will  not 
submit  to  such  tedious  treatment,  the  surgeon  must  divide  the 
constrictions  by  means  of  subcutaneous  incisions,  and  then  ex- 
tend the  fingers  upon  a  splint.  If  there  is  well-marked  gout 
in  the  system,  even  such  a  simple  operation  as  this  must  be 
undertaken  with  caution. 

CZilTB-FOOT  (TAIiIPES) 

is  the  name  applied  to  a  deformity  which  arises  from  contraction 
and  rigidity  of  the  muscles  of  the  leg. 

It  occurs  under  four  forms.  Sometimes  the  heel  is  drawn  up, 
and  the  patient  treads  upon  the  ball  of  the  foot  and  the  toes 
(talipes  eqiiinus).  This  is  the  simplest,  and  also  the  most  re- 
mediable, form  of  the  disease  (Fig.  165).     Sometimes  the  foot 


358 


DISEASES   OF  TISSUES  AND  OEGANS. 


Talipes  equinus. 


is  pointed  upwards,  and  the  weight  of  the  hody  supported  on  the 
heel  {t.  calcaneus).  This  is  a  very  rare  affection.  Sometimes 
the  foot  is  twisted  inwards,  and  the  patient  walks  on  the  outer 

edge  {t.  varus)  (Fig.  166).  Some- 
times the  foot  is  turned  outwards, 
and  the  patient  walks  on  the  inner 
edges  {t.  valgus). 

It  frequently  happens  that  these 
varieties  are  mixed.     The  equinus  is 
often      associated     with    the     varus 
{t.  equino-varus) ;    or   the  calcaneus 
with  the  valgus  (t.  calcaneo -valgus). 
Club-foot  is  generally  congenital, 
but  it  may  also   come   on  in    after- 
life.    When  this  happens,  it   is  due 
either   to — (1)  Spasmodic   irritation 
and   contraction  of  the  muscles ;    or 
(2)     paralysis    of     the    antagonistic 
muscles ;  or  (3)    the  effects  of  local 
disease  or  injury. 
The   fault  is  generally  in  the  muscles.      The  tendons,  liga- 
ments, and  bones  are  only  secondarily  affected. 

The  treatment  of  course  varies  with  the  nature  of  the  case. 
The  first  thing  is  to  ascertain  whether  the  affection  is  congenital 
or  not ;  and  if  not,  upon  what  cause  it  depends.  If  it  is  due  to 
the  irritation  of  worms,  then  a  purge  may  aid  in  removing  it. 

If  it  arises  from  debility,  then  a 
course  of  tonics,  particularly  iron, 
with  the  regular  use  of  galvanism, 
may  be  of  service.  If  it  is  associated 
with  a  rheumatic  tendency,  the 
alkalies  are  likely  to  do  good 
(F.  56,  60).  In  any  of  these  cases, 
systematic  rubbing,  and  the  applica- 
tion of  a  light  wooden  or  gutta- 
percha splint  will  be  found  of  great 
use,  and  should  never  be  omitted. 

If  the  deformity  is  so  great  that 
these  milder  measures  are  inade- 
quate, the  contracted  tendons  must 
be  divided  subcutaneously.  A 
between  the  skin  and  the  tendon 
that  is  to  be  operated  on.  The  knife  is  introduced  side- 
ways, and  then  the  edge  is  turned  down,  and  carried  through  the 
tendon.     The  knife  is  next  withdrawn,  and  the  incision  closed 


Fig.  166. 


Talipes  varus, 
tenotomy   knife   is   passed 


CLUB-FOOT. 


359 


with  a  piece  of  plaster.  This  operation  may  he  repeated  at  the 
same  time  upon  as  many  tendons  as  may  require  division.  The 
cut  ends  become  united  by  a  tendinous  structure,  which  not  only 
adds  directly  to  the  length  of  the  original  tendon,  but  also  admits 
of  a  good  deal  of  extension  while  it  is  fresh. 

In  t.  equinus  the  tendo  Achillis  must  be  divided.  The  section 
should  be  made  about  an  inch  above  its  insertion  into  the  os 
calcis.  In  this  case  it  is  safest  to  pass  the  knife  underneath  the 
tendon,  and  cut  from  within  outwards,  for  fear  of  wounding  the 
posterior  tibial  artery. 

In  t.  calcaneus  the  tibialis  anticus,  the  long  extensors  of  the 
toes,  and  the  peroneus  tertius,  may  all  require  to  be  divided 
before  the  foot  can  be  brought  down  to  its  proper  level. 

In  t.  varus  the  foot  is  turned  inwards  in  consequence  of  the 
contraction  of  the  tibialis  anticus  and  posticus.  These  are  the 
tendons,  therefore,  which  must  be  cut. 

In  t.  valgus  the  foot  is  turned  outward  by  the  action  of  the 
peroneus  longus  and  brevis.  These,  therefore,  must  be  divided, 
and  the  most  convenient  place  to  get  at  them  is  where  they  lie 
behind  the  outer  malleolus. 

When  the  deformity  is  complicated,  the  surgeon  must  use  his 
own  judgment  in  deciding  what  tendons  require  division. 

Under  any  circumstances,  the  patient  will  have  to  wear  a 
splint,  or  a  mechanical  contrivance  adapted  to  the  case,  for  some 
time  after  the  operation,  in  order  to  make  gradual  extension,  and 
to  reduce  the  foot  to  its  proper  position. 

Mr.  Barweil  has  recommended  the  use  of  elastic  bands  to  sup- 
plement the  paralysed  muscles,  and  he  has  devised  various  in- 
genious methods  of  ap- 
plying them  to  the  pa-  ^_,  pi^.  167. 
tient's  leg.  He  has 
been  led  to  this  prac- 
tice by  observing  a  pe- 
culiarly clumsy  and  im- 
perfect use  of  the  foot 
after  division  of  certain 
tendons — a  condition  he 
has  accounted  for  by 
the  false  and  unsatisfac- 
tory union  found  in  such 
cases  as  have  been  sub- 
mitted  to    post-mortem 

examination.  This  observation  refers  especially  to  the  tendons 
which  lie  immediately  behind  the  malleoli.  These,  he  believes, 
need  never  be  divided.     Moreover,  he  holds  that  the  tendon  of 


360 


DISEASES  OF  TISSUES  AND  OEGANS. 


the  tibialis  anticus,  as  well  as  the  tendo  Achillis,  require  this 
operation  much  less  often  than  is  usually  supposed.  By  manipu- 
lation, by  elastic  bands,  and  by  appropriate  splints,  he  finds  that 
many  cases  may  be  efiectually  cured  without  the  division  of 
tendons.  This  treatment  cannot  be  commenced  too  early. 
Indeed,  it  is  only  reasonable  to  suppose  that  these  milder 
measures  will  have  more  efiect  upon  the  young  and  tender  tissues 
of  an  infant  than  they  can  be  expected  to  produce  after  the  parts 
have  become  fixed  in  their  abnormal  position.  The  accompanying 
illustration  (Fig.  167)  represents  a  form  of  splint  which  Mr. 
Barwell  finds  very  convenient  for  cases  of  talipes  equinus  after 
division  of  the  tendo  Achillis. 

FIiAT  OR  SPXiAT  FOOT. 

Talipes  valgus  is  often  associated  with  the  condition  which  is 
known  as  flat  or  s^lay  foot.  The  ligaments  which  support  the 
arch  of  the  foot  give  way.     The  inner  side  of  the  sole  touches 

the  ground,  and  the 


Fig.  168. 


foot  has  a  tendency 
to  turii  outwards. 
There  is  constant 
aching  pain  in  the 
ankle,  particularly 
across  the  front  of 
the  joint,  and  the 
patient  walks  awk- 
wardly. This  com- 
plaint is  very  com- 
mon in  a  slight  de- 
gree among  young 
persons  of  both  sexes  whose  occupations  oblige  them  to  stand  or 
walk  a  great  deal.  Fig.  168  was  taken  from  a  middle-aged  man, 
whose  occupation  was  that  of  a  waiter,  and  whose  case  may  be 
considered  as  a  typical  example  of  the  disease. 

Treatment. — The  patient  should  sponge  the  feet  and  ankles 
every  morning  with  cold  water,  and  wear  a  bandage  brought  up 
on  the  inside  of  the  foot  to  support  the  arch.  He  should  also 
have  a  convex  pad  adapted  to  the  inside  of  his  shoe  so  as  to  efiect 
the  same  object.  Such  a  pad  may  be  made  of  cork,  or  of  a 
cushion  stuffed  with  horse-hair ;  or  a  few  layers  of  leather  or 
folds  of  lint,  carefully  graduated,  may  serve  the  purpose  sufli- 
ciently  well.  The  pad  should  be  worn  constantly  during  the 
day,  so  that  the  arch  of  the  foot  may  never  be  allowed  to  drop. 

In  private  practice  the  "  registered  surgical  sole,"  made  by 
Spratt,  of  Brook-street,  is  the  best  appliance  that  can  be  recom- 


GENU-VALGUM,  OR  KNOCK-KNEE.      361 

mended.  It  consists  of  an  arched  steel  spring  adapted  to  the 
size  of  the  patient's  foot.  This  is  neatly  covered  with  leather,  so  as 
to  fit  into  the  inside  of  his  shoe  or  hoot.  The  "  surgical  sole" 
can  be  worn  with  any  boots  or  shoes ;  but  a  lacing  boot  with  a 
broad  sole  is  the  best  adapted  for  its  use. 

GENU-VAZiGUXVI,  OR  XN-OCK-KITEE, 

is  an  affection  of  early  life.  It  almost  always  comes  on  between 
the  age  when  children  begin  to  walk  and  the  time  of  puberty. 
It  usually  shows  itself  in  one  knee  more  than  the  other,  but  both 
are  generally  affected  in  some  degree. 

The  legs  yield  under  the  weight  of  the  body.  The  angle 
which  naturally  exists  between  the  femur  and  the  tibia  is  in- 
creased. The  internal  lateral  ligament  is  stretched.  The 
patella  is  thrown  outwards.  The  external  lateral  ligament  and 
the  tendon  of  the  biceps  become  contracted  and  tense.  There  is 
considerable  weakness  and  constant  aching  pain. 

Treatment. — The  legs  should  be  supported,  and  the  knees  drawn 
towards  their  proper  position.  If  this  is  done  perseveringly, 
while  attention  is  paid  to  the  patient's  general  health,  a  great 
improvement  may  be  effected.  To  carry  out  these  indications, 
the  surgeon  should  provide  himself  with  a  pair  of  straight 
wooden  splints  about  three  inches  wide,  and  long  enough  to 
extend  from  the  patient's  waist  to  the  outer  ankle.  They  should 
be  perforated  with  holes  near  their  upper  end,  so  as  to  fasten  them 
to  a  waistband.  They  should  be  well  padded,  and  then  applied 
in  the  following  manner : — The  patient  should  be  undressed  from 
the  waist,  and  laid  flat  upon  a  sofa.  His  legs  should  then  be 
bandaged  with  a  common  calico  roller  from  the  toes  to  a  short 
distance  above  the  knees.  Over  this  he  should  be  allowed  to  put 
on  his  stockings  and  boots.  The  surgeon  should  then  lay  the 
splints  along  the  outer  side  of  each  leg,  taking  care  that  they  bear 
well  against  the  external  malleolus  and  the  trochanter.  In  this 
position  they  should  be  fixed  below  by  strips  of  plaster  or  bands 
of  webbing  and  buckles,  and  the  upper  ends  of  both  splints  should 
be  fastened  to  a  broad  belt  passing  round  the  waist,  so  as  to 
prevent  them  from  slipping  forwards.  Some  surgeons  recom- 
mend that  they  should  be  secured  by  a  band  passing  from  one  to 
the  other  behind  the  waist,  so  that  they  may  interfere  less  with 
the  patient's  movements.  When  the  splints  have  been  fixed  the 
knee  should  be  drawn  outwards  by  a  strap  of  webbing  secured  by 
a  buckle  or  by  a  padded  belt,  which  should  be  broad  enough  to 
cover  the  whole  knee  from  the  head  of  the  tibia  to  the  condyles 
of  the  femur.  This  must  be  kept  sufficiently  tight  to  make 
uniform  traction  upon  the  joint.     In  some  instances  it  may  be 


362  DISEASES  OF  TISSUES  AND  OEGANS. 

desirable  to  apply  a  second  bandage  up  the  whole  length  of  the 
leg,  so  as  to  draw  it  towards  the  splint.  The  apparatus  should 
be  taken  off  at  night  after  the  patient  is  in  bed,  and  readjusted 
in  the  morning  before  he  gets  up.  Unless  the  splints  are  applied 
with  care  and  attention,  and  worn  continuously  for  several 
months,  they  will  be  of  little  or  no  avail. 

When  the  patient  is  a  young  child,  he  may  with  advantage  be 
kept  in  bed  during  a  great  part  of  the  day,  with  his  legs  fixed 
between  sandbags  or  extended  by  weights  (see  Fig.  69). 

CORN'S. 

Corns  consist  of  thickened  and  hypertrophied  cuticle,  beneath 
which  the  papillae  are  enlarged  and  tender.  When  they  are 
situated  on  an  exposed  part  of  the  surface  they  are  dry  and  hard, 
but  when  they  occur  between  the  toes,  where  the  perspiration  is 
retained,  they  are  soft  and  moist.  They  are  usually  caused  by 
the  pressure  of  tight  boots,  and  their  most  frequent  seat  is  over 
the  prominences  of  bone — e.g.,  on  the  outer  side  of  the  little  toe. 
When  they  are  struck,  or  trodden  upon,  they  become  exquisitely 
painful ;  in  fact,  their  extreme  sensitiveness  haa  passed  into  a 
proverb.  When  they  become  acutely  inflamed,  the  suffering 
they  cause  is  equally  great  and  more  persistent. 

Treatment. — The  first  thing  to  be  done  is  to  remove  the  cause. 
The  patient  should  wear  boots  that  are  properly  shaped,  and 
amply  broad  across  the  toes.  A  piece  of  thick  plaster,  or  amadou, 
with  a  hole  punched  in  it  large  enongh  to  receive  the  whole  corn, 
may  be  laid  over  it  to  relieve  it  from  pressure.  With  the  view  of 
curing  the  corn,  the  hardened  cuticle  should  be  shaved  off,  or  filed 
down  daily,  and  the  part  afterwards  kept  soft  by  the  application 
of  a  little  cold  cream,  glycerine,  or  soap ;  or  it  may  be  covered 
with  a  small  piece  of  galbanum  plaster  or  of  "  Papier  Fayard." 
Care  must  be  taken  in  cutting  them  not  to  make  them  bleed — 
an  accident  which  is  very  apt  to  happen  in  consequence  of  the 
overgrowth  of  the  papillae.  If  this  should  occur,  and  any  diffi- 
culty is  found  in  arresting  the  haemorrhage,  the  application  of  a 
little  blotting-paper  or  charred  paper  will  suffice  to  stop  it ;  or 
pressure  may  be  made  by  a  bandage.  If  the  corn  is  inflamed,  it 
should  be  soaked  in  hot  water  and  poulticed.  A  poultice  made 
with  vinegar  often  gives  great  relief.  If  there  is  reason  to  think 
that  suppuration  has  taken  place,  a  puncture  should  be  made 
with  the  point  of  a  scalpel. 

Soft  corns  are  best  treated  by  the  free  application  of  lunar 
caustic  or  glacial  acetic  acid.  In  elderly  people  these  agents 
must  be  used  with  caution,  for  fear  of  inducing  gangrenous 
inflammation. 


363 


BTTUZOM'S  ILNH  DZSTORTEB  TOES. 

Bunion  is  the  name  given  to  a  swelling  formed  by  a  chronic 
inflammatory  enlargement  of  the  bursa  which  is  situated  on  the 
inner  side  of  the  head  of  the  first  metatarsal  bone.  It  is  at 
times  exquisitely  painful,  and,  if  it  becomes  acutely  inflamed  and 
suppurates,  a  thin,  unhealthy  discharge  is  apt  to  continue  for  a 
length  of  time.  It  is  generally  caused  by  the  pressure  of  boots 
that  are  too  short  as  well  as  too  narrow  across  the  toes;  and  in 
most  instances  the  great  toe  is  distorted,  and  pressed  against  the 
other  toes. 

The  pathology  and  treatment  of  the  disease  are  much  the  same 
as  those  of  inflamed  bursse  generally  (see  p.  109). 

Treatment. — The  patient  must  be  careful  to  wear  boots  that 
are  made  of  soft  and  pliable  material,  and  which  are  thoroughly 
easy.  If  the  great  toe  is 
but  little  distorted,  it 
may  be  drawn  into  its 
place  by  means  of  a  steel 
spring ;  or  by  pads  of  lint 
or  cotton-wool  between 
the  toes,  kept  in  place 
by  strips  of  adhesive 
plaster.  But  if  the  dis- 
tortion is  great,  as  in  the 
case  represented  in  Fig. 
169,  such  efi'orts  will  be 
futile.  If  the  bunion  is 
in  an  indolent  and  chronic 
state,  iodine  tinctiire,  or 
a  mercurial  ointment,  or 
a  blister    will    be   found 

suitable  applications.  If  it  becomes  acutely  inflamed,  it  must  be 
poulticed  or  leeched.  If  matter  forms,  it  should  be  let  out,  and 
care  taken  to  make  the  sac  heal  from  the  bottom.  In  any  case 
the  patient  should  give  himself  as  much  rest  as  he  can  until  the 
bunion  is  cured,  or  at  least  brought  into  a  quiescent  state;  for 
it  is  sure  to  be  aggravated  by  exercise. 


Distorted  toes. 


PART  V. 

OPERATIONS. 


Ak  operation  is  a  serious  matter,  and  ought  never  to  be  recom- 
mended without  due  consideration.  The  most  trivial  operations 
have  occasionally  been  followed  by  death,  and  the  possibility  of 
such  a  contingency  ought  always  to  be  present  to  the  surgeon's 
mind.  He  should,  therefore,  try  to  convey  to  the  patient,  or  his 
friends,  a  fair  idea  of  the  risk  to  be  incurred,  whether  it  be  great 
or  small.  In  order  to  form  a  correct  estimate  of  the  danger 
there  are  many  circumstances  which  must  be  taken  into  account — 
e.g.,  the  nature  and  extent  of  the  disease,  the  age  and  sex  of  the 
patient,  his  natural  constitution  and  temperament,  the  present 
state  of  his  health,  his  business  and  habits  of  life,  the  conditions 
in  which  he  will  be  placed  when  he  is  confined  to  bed,  and  the 
nursing  he  will  be  able  to  obtain.  All  these  are  points  of  great 
importance,  for  it  makes  a  wide  difierence  whether  he  is  young 
or  old,  of  a  sound  constitution  or  affected  with  organic  disease,  of 
a  calm  and  placid  temperament  or  irritable  and  excitable,  whether 
he  is  in  tolerable  general  health  or  worn  down  by  protracted 
suffering.  The  surgeon  must  be  on  his  guard,  and  not  mistake 
high  spirits  and  courage  for  real  strength  and  rallying  power. 
Again,  it  makes  a  great  difference  whether  the  patient's  time  is 
at  his  own  disposal,  or  whether  he  is  anxious  about  the  means  of 
earning  his  livelihood.  Whether  the  operation  is  to  be  performed 
in  town  or  in  the  country,  and  whether  or  not  skilful  nursing  can 
be  obtained,  are  points  which  should  also  be  taken  into  considera- 
tion. There  are  many  cases  in  which  one  of  the  most  important 
duties  of  the  surgeon  is  to  arrange  for  the  nursing — more  parti- 
cularly during  the  night.  Happily  this  is  not  now  a  very  diffi- 
cult matter,  as,  in  addition  to  the  numerous  private  institutions, 
there  are  so  many  training  schools  for  nurses  in  connection  with 
the  hospitals. 


OPERATIONS.  365 

Wlien  an  operation  is  necessary,  the  patient  should,  if  possible, 
be  prepared  for  it.  He  should  be  kept  quiet  for  a  few  days,  the 
secretions  regulated,  and,  if  need  be,  the  strength  supported  by 
the  administration  of  good  food  and  tonics.  It  is  of  the  utmost 
importance  that  every  function  of  the  body  should  be  in  its 
normal  state,  and  that  the  mind  should  be  calm  and  hopeful. 
Of  course,  there  are  many  operations  which  must  be  performed 
without  delay,  and  where  there  is  no  time  for  preparing  the 
patient — for  example,  the  operation  for  strangulated  hernia,  or 
an  amputation  after  injury. 

Again,  there  are  many  cases  where  other  considerations  must 
be  taken  into  account.  The  patient's  time  may  be  limited — e.g., 
he  may  be  under  orders  for  foreign  service — and  then  we  must 
be  contented  to  do  the  best  that  can  be  done  under  the  circum- 
stances. 

In  some  operations  upon  the  limbs  it  is  well,  before  using  the 
knife,  to  put  on  "  Esmarch's  bandage."  This  is  merely  an  elastic 
roller  which  is  applied  from  the  extremity  upwards.  At  the 
highest  point  to  which  it  is  carried  an  elastic  cord  is  tied  round 
the  limb,  and  then  the  bandage  is  removed.  It  will  be  found 
that  the  blood  has  been  to  a  great  extent  driven  out  of  the  part, 
and  that  there  is  little  or  no  haemorrhage  as  the  incisions  are  being 
made.  When  the  operation  is  finished,  the  elastic  cord  is 
gradually  relaxed,  and  then  the  bleeding  vessels  can  be  secured. 

The  surgeon  should  himself  see  that  everything  is  ready  for 
the  operation — that  the  table,  or  couch,  is  firm,  of  a  convenient 
height,  and  well  situated  for  light — that  there  is  a  sufficient 
supply  of  sponges  and  water — that  every  instrument  which  can 
possibly  be  required  is  at  hand,  and  within  easy  reach — that  the 
necessary  splints,  dressings,  and  bandages  are  in  readiness.  Ke 
should  have  a  sufficient  number  of  assistants,  but  no  more ;  and 
each  should  understand  beforehand  what  are  his  special  duties. 
In  the  case  of  a  capital  operation,  three  or  four  will  be  necessary. 
If  chloroform  is  to  be  used,  its  administration  must  be  entrusted 
to  a  competent  person,  and  he  should  make  it  his  sole  business,  so 
that  the  operator  may  have  no  anxiety  on  that  score.  The  sur- 
geon should  take  his  stand  in  the  most  convenient  position,  and 
from  that  place  he  should  not  move  till  the  operation  is  com- 
pleted. There  should  be  silence  during  its  performance ;  and  a 
word,  a  look,  a  gesture,  is  all  that  should  be  necessary  on  the 
part  of  the  surgeon  to  guide  the  movements  of  his  assistants. 
Everything  should  be  done  quietly  and  deliberately,  without 
hurry  and  without  loss  of  time. 


366  OPEEATIONS. 


ZM-cisioirs. 

The  scalpel  may  be  held  like  a  carving  knife,  or  like  a  pen,  or 
like  a  fiddlestick,  or  in  other  ways  which  the  requirements  of  the 
case  and  the  dexterity  of  the  surgeon  will  suggest. 

Before  commencing  an  incision,  the  skin  should  be  gently 
stretched  with  the  left  hand.  The  point  of  the  scalpel  should  be 
introduced  at  right  angles  to  the  surface,  and  carried  quite 
through  the  skin ;  the  handle  should  then  be  depressed,  and  the 
blade  drawn  along  as  far  as  necessary ;  the  handle  again  raised, 
and  the  knife  withdrawn  at  right  angles  to  the  surface,  as  before. 
Sometimes,  the  superficial  incision  is  made  by  transfixion.  A  fold 
of  skin  is  raised  between  the  forefinger  and  thumb  of  the  left 
hand,  pierced,  and  then  the  blade  is  made  to  cut  from  within 
outwards.  In  any  case,  a  sufficient  incision  in  the  skin  should  be 
made  at  the  outset.  It  should  not  be  needful,  except  under 
special  circumstances,  to  enlarge  it  afterwards. 

AXa-JESTHETICS. 

The  history  of  ansesthetics  is  a  subject  full  of  interest,  but  it  is 
one  on  which  I  cannot  here  enter.  Suffice  it  to  say  that  the  in- 
troduction of  ether  in  1846  is  due  to  Mr.  Morton,  a  dentist  of 
Boston,  U.S.A. ;  while  it  was  Sir  James  Simpson  who  drew  the 
attention  of  the  profession  in  1847  to  chloroform — an  anaesthetic 
which  is  more  convenient  than  ether,  and  which  is  now  very 
largely  used  in  this  country. 

Administration  of  chloroform. — The  patient  should,  if  possible, 
abstain  from  food  for  three  or  four  hou7s  before  the  chloroform  is 
to  be  given,  or  take  only  a  little  beef-tea  or  wine.  When  the 
stomach  is  full,  sickness  is  very  apt  to  o(!cur.  He  should  be 
placed  in  the  recumbent  position,  lying  on  his  back,  and  arranged 
as  if  for  sleep.  The  administrator  should  keep  his  hand  on  the 
pulse,  watch  the  breathing  and  the  colour  of  the  lips,  and  from 
time  to  time  examine  the  state  of  the  pupils. 

When  a  slight  and  transient  insensibility  is  all  that  is  wanted, 
chloroform  may  be  given  on  a  handkerchief,  or  on  a  fold  of  lint ; 
and  this  will  generally  be  found  the  best  plan  in  dealing  with 
infants.  But  when  deep  and  prolonged  narcotism  is  necessary  in 
the  adult,  an  inhaler  had  better  be  used. 

At  first,  a  small  quantity  of  chloroform — say,  ^j  for  an  adult — 
should  be  sprinkled  on  the  lint,  and  it  should  be  held  in  front  of 
tlie  patient's  nose  and  mouth,  at  a  distance  of  a  couple  of  inches. 
After  a  few  respirations,  it  should  be  brought  a  little  nearer,  and 
thus  the  dose  should  be  gradually  increased ;  but  the  saturated 


ANESTHETICS.  367 

lint  should  never  be  placed  so  near  the  face  as  to  prevent  the  free 
admixture  of  atmospheric  air  with  the  vapour  of  the  chloroform. 
If  an  inhaler  is  used,  the  valve  should  be  kept  open  at  first,  and 
closed  by  degrees.  It  is  of  great  importance  that  the  dose  should 
be  small  at  first,  and  gradually  increased,  so  that  the  air-passages 
may  become  accustomed  to  the  vapour.  Moreover,  there  is 
reason  to  think  that  the  first  inhalation  of  a  large  dose  of  chloro- 
form has  sometimes  caused  instant  death  by  spasm  of  the  glottis, 
or  paralysis  of  the  heart. 

If  a  fold  of  lint  or  an  ordinary  inhaler  is  used,  the  amount  of 
chloroform  vapour  which  the  patient  breathes  must  be  very  un- 
certain— sometimes  it  will  be  more  and  sometimes  less ;  and  very 
probably  it  will  be  greatest  at  first,  when  it  is  desirable  that 
it  should  be  least.  To  obviate  these  disadvantages,  Mr.  Clover 
has  invented  an  apparatus  whereby  the  per-centage  of  chloroform 
to  atmospheric  air  can  be  regulated  exactly.  A  measured  quan- 
tity of  chloroform  and  a  measured  quantity  of  atmospheric  air  are 
introduced  into  a  large  air-tight  bag,  which  is  fitted  with  a 
flexible  tube  and  a  mouthpiece.  Thus  the  dilution  of  the  chloro- 
form vapour  can  be  ascertained  with  great  nicety,  and  under  no 
circumstances  can  the  patient  breathe  a  larger  proportion  of  the 
anaesthetic  than  that  which  has  been  predetermined  by  the 
surgeon.  The  apparatus  is,  unfortunately,  rather  cumbrous; 
but,  notwithstanding  this  drawback,  it  is  by  far  the  best  means 
of  administering  chloroform  that  has  yet  been  devised ;  and 
nothing  can  be  more  satisfactory  than  the  success  which  has 
attended  its  use  in  Mr.  Clover's  hands. 

The  first  efiect  of  chloroform  is  to  produce  a  slight  excitement. 
The  pulse  is  quickened ;  the  spirits  are  raised  ;  and  the  mind  is 
active,  but  not  quite  under  control.  The  patient  struggles,  talks 
loudly  and  incoherently,  or  perhaps  sings  ;  still  there  is  perfect 
sensibility  to  pain.  Gradually,  these  symptoms  give  way,  and 
he  falls  into  a  deep  sleep.  The  breathing  is  slightly  stertorous. 
Voluntary  motion  and  sensation  are  suspended,  but  the  sphincters 
are  not  relaxed.  Soon,  reflex  movements  can  no  longer  be 
excited;  if  the  eyeball  is  touched,  or  the  nostril  tickled,  no 
attempt  is  made  to  resent  the  irritation.  This  is  the  state  of 
complete  insensibility  in  which  the  patient  should  be  placed  when 
the  operation  is  commenced.  If  the  chloroform  is  pushed  farther 
than  this,  the  breathing  becomes  slow,  and  very  stertorous,  the 
face  congested,  the  pupils  dilated,  and  there  is  a  tendency  to 
death  by  coma. 

Thus  it  will  be  seen  that  chloroform  acts  upon  the  brain  from 
its  circumference  to  its  centre.  First,  the  intellectual  faculties 
are  disturbed  j  then,  the  central  ganglia  of  motion  and  sensation. 


368  OPERATIONS. 

with  which  the  spinal  cord  is  in  communication,  hecome  aflPected  ; 
and,  when  the  influence  of  the  drug  extends  to  the  medulla 
oblongata,  respiration  is  apt  to  cease.  When  chloroform  destroys 
life  in  this  way,  it  acts  like  a  poisonous  dose  of  opium,  or  of 
alcohol.  In  such  cases,  the  heart  continues  to  beat  for  a  few 
minutes  after  the  action  of  the  lungs  has  stopped. 

If  the  patient  retches,  and  is  inclined  to  vomit,  his  head  should 
be  turned  on  one  side,  so  as  to  facilitate  the  escape  of  matters 
from  his  mouth. 

If  he  struggles  violently,  the  chloroform  should  be  removed 
for  a  moment ;  and,  as  soon  as  he  is  composed,  the  administration 
should  be  continued. 

As  long  as  the  pulse  is  good,  and  the  breathing  regular,  there 
is  no  cause  for  alarm.  When  the  chloroform  has  been  pushed  to 
excess,  there  is,  as  we  have  just  said,  danger  of  death  by  coma ; 
but  this  is  not  the  only  way  in  which  it  extinguishes  life.  Some- 
times it  seems  to  act  by  paralysing  the  heart.  This  is  particularly 
apt  to  occur  when  the  cavities  are  dilated,  and  the  muscular  tissue 
is  thin  and  in  a  state  of  fatty  degeneration.  When  it  proves 
fatal  in  this  way,  death  may  occur  at  the  first  inspiration,  or  at 
any  time  during  the  administration. 

If  the  patient  is  old  or  debilitated — if  the  impulse  of  the  heart 
is  feeble,  the  sounds  indistinct,  the  pulse  weak ;  or  if  there  is  a 
well-marked  arcus  senilis ;  or  if  the  circulation  through  the  lungs 
is  impeded — the  utmost  care  should  be  used  in  administering 
chloroform.  It  should  also  be  remembered  that  in  some  cases  the 
patient  receives  an  additional  shock  from  the  nature  of  the  opera- 
tion, as,  for  example,  when  the  spermatic  cord  is  divided. 

There  are  some  operations  which  it  is  better  to  perform  with- 
out chloroform.  Speaking  generally,  they  may  be  summed  up 
under  two  heads :  (1)  operations  about  the  back  of  the  mouth — 
excision  of  the  tonsils,  for  example — where  there  is  danger  of  the 
blood  finding  its  way  into  the  glottis,  and  producing  suffocation ; 
and  (2)  operations  in  which  we  require  the  assistance  of  the 
patient — for  example,  in  the  ligature  of  internal  piles. 

As  a  general  rule,  chloroform  should  not  be  given  when  a 
minute's  fortitude  on  the  part  of  the  patient  will  enable  him  to 
endure  all  that  has  to  be  done.  The  occasion  does  not  justify 
the  risk. 

If  death  seems  imminent,  whether  it  be  by  syncope  or  by  coma, 
restorative  measures  should  be  adopted  without  delay.  The 
windows  should  be  opened,  the  patient's  tongue  drawn  forward, 
the  face  and  chest  dashed  with  cold  water,  ammonia  held  to  the 
nostrils,  the  chest  rhythmically  compressed,  artificial  respira- 
tion performed,  and  galvanism  applied  over  the  heart. 


DKESSINGS.  369 

JSther  has  always  been  a  favourite  ana3sthetic  in  America,  and 
from  time  to  time  it  has  been  extensively  used  in  this  country. 
At  present,  English  surgeons  are  employing  it  largely.  Some- 
times it  is  administered  throughout  the  whole  operation ;  some- 
times the  patient  is  brought  fully  under  its  influence,  and  then 
the  effect  is  kept  up  with  chloroform.  There  can  be  no  doubt 
that  it  is,  on  the  whole,  safer  than  chloroform ;  but  its 
administration  takes  a  longer  time,  is  apt  to  be  attended  by  more 
excitement,  and  followed  by  more  unpleasant  after-symptoms. 
By  a  judicious  combination  of  the  two  substances  we  may  hope  to 
secure  the  best  influences  of  each,  and  to  avoid  their  disad- 
vantages. 

The  bichloride  of  methylene  is  another  substance  which  has 
lately  been  used  by  some  surgeons  as  an  anaesthetic.  The 
advantages  which  it  is  said  to  possess  over  chloroform  are  that  it 
produces  insensibihty  more  rapidly,  that  there  is  less  muscular 
rigidity,  that  recovery  takes  place  more  quickly,  and  that  it  is  less 
liable  to  be  followed  by  disagreeable  consequences. 

The  nitrous  oxide,  or  laughing  gas,  has  been  introduced  into 
practice  by  the  American  surgeons,  and  has  now  taken  its  place 
as  a  recognised  anaesthetic.  As  the  insensibility  it  produces  can- 
not safely  be  prolonged  beyond  a  few  minutes,  it  is  not  suitable 
for  general  surgery ;  but  for  short  operations,  such  as  the  majority 
of  those  in  dentistry,  it  is  a  very  valuable  agent. 

Local  Ancesthesia. — Local  and  superficial  insensibility  may  be 
produced  by  using  a  mixture  of  pounded  ice  and  salt — two-thirds 
of  ice  and  one-third  of  salt.  The  mixture  should  be  made 
rapidly,  placed  in  a  muslin  bag,  and  laid  upon  the  part.  In  five 
or  ten  minutes  the  skin  becomes  white,  hard,  and  insensible  to 
pain.  After  the  operation,  it  should  be  allowed  to  recover  itself 
slowly.     Heat  should  on  no  account  be  applied. 

But  this  means  of  producing  local  insensibility  has  been  well- 
nigh  superseded  by  Dr.  Richardson's  method,  which  consists  in 
throwing  a  spray  of  highly-rectified  ether  upon  the  part.  By  the 
rapid  evaporation  which  the  ether  undergoes,  the  skin  is  frozen, 
and  rendered  insensible  to  pain.  Richardson's  apparatus  is 
simple,  and  can  be  obtained  at  any  surgical-instrument  maker's. 

Local  anaesthesia,  however,  is  only  applicable  to  slight  opera- 
tions— opening  abscesses,  removing  small  tumours,  and  the  like. 

DRESSISJGS. 

A  vast  improvement  has  taken  place  of  late  years  in  the  mode 
of  dressing  wounds.  The  present  practice  is  characterised  by 
great  simplicity,  and  by  a  studious  regard  to  cleanliness.  It  is 
also  the  aim  of  the  surgeon  to  lay  aside  all  needless  appliances, 

B  B 


370  OPERATIONS. 

to  remove  all  sources  of  discomfort,  and  to  diminish,  as  far  as  he 
can,  pain  and  suffering.  A  great  deal  may  be  done  to  carry  out 
these  objects  by  forethought,  by  minute  attention  to  details,  and 
by  a  gentle  hand.  If  a  patient  can  be  kept  perfectly  at  rest, 
both  in  body  and  mind,  he  is  placed  in  the  most  favourable  cir- 
cumstances for  recovery, 

I  have  already  said  that  the  aim  of  modern  surgery  is  to  reduce 
suppuration  to  a  minimum,  and,  whenever  it  is  possible,  to  get  rid 
of  it  altogether.  With  this  view,  various  applications  have  been 
used,  and  various  methods  of  dressing  have  been  tried.  Of  these 
applications  the  most  eflScient  is  carbolic  acid,  and  the  most 
effectual  way  of  applying  it  is  that  which  is  carried  out  by  Mr. 
Lister,  and  which  I  have  elsewhere  described  (see  p.  14).  But 
whether  carbolic  acid  (F.  12),  or  sulphurous  acid  (F.  24),  or  chlo- 
ride of  zinc  (F.  14),  or  any  other  substance,  is  used,  it  is  of  the 
first  importance  that  it  should  be  brought  thoroughly  and  con- 
tinuously into  contact  with  the  wound.  The  plan  which  Mr. 
Lister  adopts  secures  this  object  perfectly.  The  only  fault 
that  can  be  found  with  it  is  that  it  is  too  complicated — that 
it  requires  too  much  time  and  attention  from  the  surgeon.  If  it 
could  be  made  more  simple,  I  believe  it  would  be  one  of  the  most 
far-reaching  improvements  in  modern  surgery.  At  Charing 
Cross  Hospital,  Mr.  Hancock  has  had  some  excellent  results, 
after  important  operations,  by  merely  washing  out  the  wound 
thoroughly  with  a  carbolized  lotion,  covering  it  with  lint,  and 
allowing  a  weak  carbolic  lotion  to  drop  constantly  upon  it  from  a 
syphon  bottle. 

Some  surgeons  prefer  to  get  rid  of  all  moist  applications,  and 
to  use  only  dry  dressings.  Thus,  a  wound  may  be  carefully  washed 
out,  accurately  stitched  together,  and  then  the  edges  sealed  with 
collodion.  Friar's  balsam,  or  "  colloid  styptic."  This  method  is 
best  suited  to  wounds  of  moderate  size  in  parts  that  are  highly 
vascular,  such  as  the  face  or  scalp.  In  larger  wounds,  after  care- 
ful closure,  a  pad  of  "  tenax."  (i.e.,  finely  carded  oakum)  or  of  dry 
lint  may  be  laid  over  the  whole  surface,  and  firmly  secured  by  a 
bandage.  This  method  is  very  suitable  to  the  wound  left  after  the 
removal  of  a  tumour — e.cf.,  of  the  breast.  When  such  dressings 
as  these  are  employed,  it  is  no  uncommon  thing  to  find  that  the 
whole,  or  a  great  part,  of  a  wound  unites  by  adhesive  inflamma- 
tion. But  these  methods  of  dressing  are  only  applicable  to  cases 
in  which  we  may  reasonably  expect  that  there  will  be  no  slough- 
ing— that  no  considerable  part  of  the  tissues  will  have  to  be  thrown 
off  before  repair  can  begin,  but  that  all  within  the  incision  will 
retain  its  vitality  and  become  united  together. 

If  the  case  is  not  suitable  for  dry  dressings,  and  if  the  sur- 


DRESSINGS.  371 

geon  does  not  think  proper  to  adopt  any  antiseptic  method,  then 
it  is  customary  to  cover  the  wound  with  a  few  folds  of  wet  lint 
covered  with  oiled  silk  (water-dressing);  and  to  secure  them  by 
means  of  a  bandage.  Sometimes  narrow  strips  of  lint,  spread 
with  vaseline  or  simple  cerate,  are  laid  along  the  incisions,  to 
prevent  the  folds  of  lint  from  becoming  adherent.  These  dress- 
ings are  not  disturbed  for  a  couple  of  days,  except  under  special 
circumstances.  Subsequently,  the  wound  is  treated,  if  need  be, 
with  a  suitable  lotion,  or  a  poultice. 

When  suppuration  takes  place,  if  it  is  moderate  in  amount 
and  healthy  in  character,  all  that  need  be  done  is  to  receive  the 
discharge  on  lint,  which  should  be  frequently  changed. 

If  the  neighbourhood  of  the  wound  becomes  red,  swollen,  and 
painful,  if  there  are  the  signs  of  inflammation,  then  we  must 
apply  a  poultice  or  a  bladder  of  ice ;  whichever  is  found  to  give 
the  patient  most  relief  will  be  best  for  the  wound. 

Cold  seems  to  act  by  constricting  the  vessels,  so  as  to  diminish 
the  quantity  of  blood  in  the  part,  and  by  absorbing  the  heat  that 
is  generated ;  while,  at  the  same  time,  it  relieves  pain  by  deaden- 
ing the  sensibility  of  the  nerves.  Continuous  cold  can  only  be 
thoroughly  maintained  by  a  bladder  of  ice,  by  an  ice  poultice 
(F.  97),  or  by  irrigation — that  is  to  say,  by  causing  iced  water,  or 
evaporating  lotion,  to  drop  constantly  on  the  aflected  part,  or  on 
a  fold  of  lint  laid  over  it. 

Heat  combined  with  moisture  relaxes  the  tissues,  dilates  the 
vessels,  favours  exudation,  and  allows  the  circulation  to  be  carried 
on  more  easily.  This  is  one  of  the  special  uses  of  a  poultice — it 
allays  inflammation  by  relieving  the  tension  of  the  circulation. 
Fomentations — that  is  to  say,  flannels  wrung  out  of  hot  water 
(plain  or  medicated),  and  enveloped  in  oiled  silk — and  water - 
dressing,  act  in  the  same  way,  but  less  efficiently. 

There  are,  however,  other  conditions  in  which  heat  and  mois- 
ture are  extremely  useful.  When  a  part  is  lacerated  or  contused, 
when  it  is  clear  that  sloughs  must  come  away  before  repair 
can  begin,  then  a  poultice  is  applied  with  advantage.  It  would 
seem  that  the  natural  processes  go  on  with  greater  rapidity  in 
the  warm  and  moist  atmosphere,  which  is  kept  up  by  this  means. 
The  disintegration  of  the  dead  tissues  takes  place  more  quickly, 
the  sloughs  separate  in  a  shorter  time ;  and,  when  once  a  clean 
surface  has  been  produced,  the  granulations  spring  up  with  a 
more  luxuriant  growth. 

If  poultices  are  continued  too  long,  the  granulations  are  apt 
to  become  large,  pale,  and  flabby — constituting  what  is  popu- 
larly called  "  proud  flesh" — and  the  surrounding  tissues  become 
sodden.     In  such  a  case  the  poultices  should  be  discontinued,  and 

B  B  2 


372  OPERATIONS. 

the  wound  dressed  with  a  stimulating  lotion.  Sometimes  great 
benefit  may  arise  from  exposing  it  for  a  few  hours  to  the  air. 
If  the  granulations  are  exuberant,  they  should  be  freely  touched 
with  lunar  caustic. 

If  the  suppuration  is  excessive,  the  wound  should  be  bathed  or 
syringed  with  an  astringent  lotion,  or  dressed  with  lint  dipped 
in  it  (F.  12,  14,  27). 

If  the  discharge  is  very  offensive,  lint  saturated  with  a  disin- 
fecting lotion  should  be  applied  to  the  wound,  and  a  poultice  laid 
over  it;  or  the  poultice  may  be  mixed  with  charcoal  or  yeast. 

In  those  distressing  cases  in  which  the  patient's  urine  is  con- 
stantly dribbling  away,  it  is  a  good  plan  to  lay  a  pillow  of  char- 
coal between  the  thighs  and  under  the  perineum. 

COXarSTITUTIOXTAZi  TREikTni&rrT  AFTER 
OPERiLTIOia'S. 

After  a  trifling  operation  it  is  not  necessary  to  make  any 
change  in  the  patient's  way  of  living,  provided  that  proper  atten- 
tion is  paid  to  the  state  of  the  bowels. 

After  a  second-rate  operation  the  patient  should  be  confined  to 
bed  or  to  the  sofa  for  a  few  days,  the  diet  should  be  somewhat 
restricted,  and  a  laxative  prescribed  every  evening. 

After  a  capital  operation,  where  there  is  sure  to  be  more  or  less 
fever,  the  patient  should  take  a  saline  (F.  33,  35,  69),  his  bowels 
should  be  freely  opened  every  day,  and  his  diet  should  consist  of 
beef-tea,  broth,  milk,  eggs,  light  puddings,  &c.  In  some  cases 
an  alcoholic  stimulant  will  be  required.  This  is  particularly  the 
case  when  the  patient  is  old,  or  enfeebled  by  previous  disease,  or 
when  he  has  been  prostrated  by  the  shock  of  the  operation,  or  by 
hsemorrhage.  As  a  general  rule,  brandy  or  port  wine  are  the 
best ;  but  it  is  often  the  wisest  plan  to  give  the  patient  what- 
ever he  has  been  accustomed  to  drink,  or  whatever  he  fancies  at 
the  time.  Egg-flip  is  of  great  use  in  extreme  exhaustion  (F.  100); 
and,  at  the  same  time,  ammonia  and  spirits  of  chloroform  may 
be  freely  given  (F.  35).  But  alcohol  should  not  be  given  unless 
there  is  good  reason. 

Some  surgeons  make  a  practice  of  ordering  a  grain  of  opium 
or  a  sedative  draught  to  be  taken  every  six  hours  after  a  capital 
operation,  with  the  view  of  allaying  nervous  irritability  ;  and  the 
practice  is  one  which  may  often  be  followed  with  advantage, 
especially  in  persons  of  an  excitable  temperament.  Under  any 
circumstances,  it  is  a  good  plan  to  give  a  full  dose  of  opium  or 
morphia  the  night  after  a  severe  operation,  to  allay  pain  and 
procure  sleep. 


373 


Fig-.  170. 


VEUESECTZOHr. 

Fifty  years  ago  venesection  used  to  be  much  more  often  prac- 
tised than  it  is  at  the  present  time.  Persons  now  living  can 
remember  when  those  in  good  health 
thought  it  necessary  to  be  bled  every  spring, 
or  every  spring  and  autumn.  Bleeding 
entered  largely  into  the  regimen  to  which 
pregnant  women  were  subjected;  and 
there  is  reason  to  fear  that  many,  like 
the  Princess  Charlotte,  succumbed  to  its 
lowering  influence  (see  the  "  Memoirs  of 
Baron  Stockmar,"  i.  65).  In  the  treat- 
ment of  disease  the  lancet  was  freely  used, 
and  the  amount  of  blood  that  was  some- 
times drawn  is  almost  incredible.  Insanity, 
in  all  its  forms,  was  supposed  to  depend 
upon  inflammation  of  the  brain,  and  was 
to  be  cured  by  blood-letting ;  while  many 
morbid  states  which  we  now  know  to  be 
far  removed  from  sthenic  inflammation, 
were  treated  in  the  same  manner. 

But  all  this — so  far,  at  least,  as  British 
medicine    and    surgery  are   concerned — is 
now  happily  changed.     It  is  now  held  that  "the  blood  is  the 
life,"  and  it  is  our  study  to  maintain  its  quantity,  to  preserve 


Bandage  before  vene- 
section. 


Fiff.  171. 


its  purity,  and  to  regulate  its  dis- 
tribution. There  should,  there- 
fore, be  very  clear  evidence  to  act 
upon,  and  some  very  special  benefit 
to  obtain,  before  general  blood- 
letting is  resorted  to. 

Venesection  is  generally  per- 
formed at  the  bend  of  the  elbow. 
A  broad  roller  is  tied  round  the 
arm  a  little  above  the  elboAv,  tight 
enough  to  compress  the  superficial 
veins,  without  arresting  the  deep 
circulation  (Fig.  170).  The  sur- 
geon then  selects  the  vein  to 
be  opened — the  median  cephalic 
or  the  median  basilic,  the  former, 
if  possible — places  his  thumb  on 
pushes   his   lancet   obliquely    through  it,   so  as  to   lay  it  open 


Bandage  after  venesection, 
the   lower   part  of  it,  and 


374  OPERATIONS. 

without  dividing  it.  When  the  required  quantity  of  hlood  has 
been  drawn,  he  puts  a  small  compress  of  lint  on  the  bleeding 
point,  fixes  it  with  a  strip  of  plaster  and  a  figure-of-8  bandage 
(Fig.  I7l),  and  then  undoes  the  roller. 

If  the  jugular  vein  has  to  be  opened,  the  incision  should  be 
carried  obliquely  downwards  and  inwards,  so  as  to  cross  the  fibres 
of  the  platysma. 

THE  CAUTERV,  ISSUES,  SETOITS. 

Counter-irritation  is  sometimes  made  by  means  of  the  actual 
cautery,  or  by  issues,  or  by  setons. 

If  the  actual  cautery  is  used,  the  iron,  heated  to  a  dull  red 
heat,  is  drawn  lightly  over  the  skin,  sometimes  in  parallel  lines 
and  cross-bars,  like  an  heraldic  portcullis.  The  gas  cautery, 
which  was  devised  by  the  late  Mr.  Bruce,  and  Dr.  Paquelin's 
thermo-cautere  are  convenient  means  of  heating  the  metal  points 
and  keeping  them  at  the  required  temperature. 

The  moxa  is  a  peculiar  method  of  applying  cauterization.  A 
small  cone  is  formed  of  muslin  soaked  in  solution  of  nitre.  It 
is  then  placed  on  the  skin,  and  the  apex  is  ignited.  It  is  allowed 
to  burn  slowly  down,  and  the  result  is  an  eschar,  corresponding 
in  size  to  the  base  of  the  cone.  The  surrounding  skin  should  be 
protected  by  a  fold  of  wet  lint,  with  a  hole  cut  in  it. 

Counter-irritation  by  means  of  the  actual  cautery,  or  the 
moxa,  is  particularly  applicable  to  deep-seated  and  chronic  disease 
of  the  joints  and  bones. 

Issues  may  be  made  either  with  caustic  or  by  an  incision. 

If  caustic  is  preferred,  the  best  is  a  thick  paste  composed  of 
potassa  fusa  and  bread-crumbs  or  soft  soap.  A  piece  of  thick 
leather  plaster,  with  a  hole  cut  in  it  the  size  of  the  desired  issue, 
should  be  laid  on  the  part,  the  paste  applied  to  the  skin,  which  is 
visible  at  the  aperture,  and  retained  by  a  strip  of  plaster.  For 
four  or  five  hours  the  patient  experiences  a  burning  pain. 
An  eschar  is  formed,  which  must  be  poulticed  till  it  separates, 
and  then  the  raw  surface  should  be  dressed  with  savine  ointment. 

If  the  issue  is  to  be  made  by  incision,  a  fold  of  skin  is  raised 
between  the  finger  and  thumb  of  the  left  hand,  transfixed,  and  the 
knife  made  to  cut  its  way  from  within  outwards.  To  increase 
the  effect,  a  string  of  issue-beads  or  dry  peas  is  sometimes  laid 
along  the  incision,  and  secured  by  strips  of  plaster. 

An  issue  should  never  be  made  directly  over  a  projecting  pro- 
cess of  bone.  In  all  cases  the  wound  ought  to  be  confined  to  the 
skin ;  if  it  extends  farther,  it  may  lead  to  a  troublesome  sore. 
When  the  raw  surface  ceases  to  discharge  healthily,  the  sooner  it 
is  healed  the  better. 


LARYNGOTOMY  AND  TRACHEOTOMY.  375 

A  seion  is  made  by  lifting  up  a  fold  of  skin  between  the  finger 
and  thumb,  and  piercing  it  with  a  narrow-bladed  knife.  The 
author's  grooved  knife,  represented  in  Fig.  172,  is  very  suitable  for 
the  purpose.     An  eyed  probe,  armed  with  two  or  three  threads  of 

Fior.  172. 


silk,  is  then  passed  through  the  wound,  or  along  the  groove  of  the 
knife,  and  the  ends  tied  together.  Or,  in  minor  cases,  a  large 
needle,  doubly  threaded  with  stout  silk,  may  be  passed  through  a 
fold  of  skin,  and  the  ends  tied  as  before.  The  loop  thus  formed 
should  be  moved  a  little  every  day  to  keep  up  irritation. 

XiAR'S'ia-GOTOIVI'S-  AND  TRACBEOTOM7. 

It  is  often  necessary  to  make  an  opening  into  the  windpipe 
when  the  larynx  is  obstructed,  or  when  there  is  a  foreign  body  in 
the  bronchi. 

The  obstruction  of  the  larynx  may  arise  either  from  acute  or 
chronic  disease,  or  from  the  impaction  of  a  foreign  body. 

The  acute  diseases  most  likely  to  require  operative  treatment 
are  oedema  glottidis,  erysipelas  of  the  larynx,  diphtheria,  and,  in 
the  adult,  acute  laryngitis. 

The  chronic  diseases  are  chronic  inflammation  of  the  larynx 
with  thickening  or  ulceration ;  morbid  growths,  either  in  the 
larynx  itself,  or  pressing  upon  it  from  without. 

When  a  foreign  body,  such  as  a  morsel  of  food,  has  become  im- 
pacted in  the  larynx,  it  is  necessary  to  open  the  windpipe  at  once, 
to  prevent  suffocation ;  and  when  a  foreign  body  has  been 
drawn  into  the  bronchi,  an  artificial  opening  may  be  needful  to 
facilitate  its  expulsion. 

When  an  operation  has  become  necessary,  the  question  arises, 
where  shall  t^ie  windpipe  be  opened  ?  The  surgeon  has  a  choice 
of  situations.  He  may  perform  laryngotomy,  laryngo-tracheotomy, 
or  tracheotomy . 

Laryngotomy  consists  in  cutting  vertically  through  the  skin 
and  fascia,  exposing  the  crico-thyroid  membrane,  and  then  dividing 
it  by  a  transverse  incision.  The  crico-thyroid  membrane  may 
easily  be  recognised  by  the  depression  which  it  forms  about  an 
inch  below  the  pomum  AdamL  This  operation  is  only  applicable 
to  adults. 

In  laryv go-tracheotomy  the  deep  incision  is  carried  downwards 


376 


OPERATIONS. 


from  the  crico-thyroid  membrane,  through  the  cricoid  cartilage 
and  one  or  two  of  the  upper  rhigs  of  the  trachea. 

Tracheotomy  is  a  more  difficult  and  dangerous  operation  than 
either  of  the  preceding.  It  may  be  performed  either  above  or 
below  the  isthmus  of  the  thyroid  gland.  The  patient's  head 
should  be  thrown  back,  so  as  to  stretch  the  neck.  An  incision, 
about  an  inch  and  a  half  long,  should  then  be  made  through  the 
skin  and  superficial  fascia.  The  dissection  should  be  carried  on, 
partly  with  the  point  of  the  knife  and  partly  with  the  handle, 
between  the  sterno-hyoid  and  sterno-thyroid  muscles  of  each 
side,  until  the  rings  of  the  trachea  are  exposed.  As  far  as  pos- 
sible the  larger  veins  should  be  avoided ;  if  any  are  divided,  they 
should  be  tied  at  once.  The  capillary  haemorrhage  should  be 
restrained  by  gentle  pressure,  or  by  cold  water,  before  the  wind- 
pipe is  opened.  When  the  bleeding  has  ceased,  the  surgeon 
steadies  the  trachea  with  a  hook  or  with  his  finger,  and  then 
pushes  the  point  of  his  scalpel  through  it,  and  cuts  from  helow 
vpivards,  dividing  three  or  four  of  the  rings.  The  knife  should 
be  lightly  held  in  the  wound,  so  as  to  form  a  guide  upon  which 
the  tube  can  be  slipped  into  the  trachea.  If  this  is  not  done — if 
the  surgeon  once  withdraws  his  knife — he  may  find  it  very  diffi- 
cult to  introduce  the  tube.  The  grooved  knife  represented  in 
Fig.  172  is  well  suited  to  form  a  guide  into  the  winflpipe. 

The  isthmus  of  the  thyroid  gland  should  be  pushed  upwards  or 
downwards,  according  to  the  seat  of  the  operation. 

Tracheotomy  below  the  isthmus  is  a  more  formidable  operation 
than  when  the  opening  is  made  above  that  point.  In  this  situa- 
tion the  trachea  lies  deeper,  it  is  more  covered,  and  it  comes 
into  close  relation  with  some  very  important  parts.  Superficially, 
it  is  covered  by  the  inferior  thyroid  plexus  of  veins.  The  inno- 
minate artery  lies  just  behind  the  upper  border  of  the  sternum, 
and  may  even  rise  higher ;  and  there  may  be  a  "  thyroidea  ima" 
coursing  up  the  front  of  the  trachea  itself. 

Fig,  173. 


Outer  and  inner  tracheotomy  tubes  (Fuller's). 

The  tubes  that  are  generally  used  are  those  which  are  double 
— the  inner  one  (Fig.  173,  h)  fitting  accurately  into,  and  project- 


LARYNGOTOMY  AND  TRACHEOTOMY. 


377 


Fig:.  174, 


ing  a  little  beyond,  the  outer  one  (Fig.  173,  a).  If  one  of  these 
is  used,  the  inner  tube  can  be  withdrawn  from  time  to  time,  and 
cleaned.  When  the  outer  tube  is  split  up  the  middle,  and 
reduced  to  two  lateral  pieces,  which  can  be  pressed  together  at 
the  point  so  as  to  form  a  wedge,  it  very  much  facilitates  its  intro- 
duction.   These  are  known  as  Fuller's  bivalve  tubes. 

But  it  is  obvious  that  a  stiff,  hard  tube,  such  as  this,  must 
sometimes  press  unduly  against  the  posterior  wall  of  the  trachea. 
To  remove  this  objection,  various  suggestions  have  been  made. 
Mr.  Bryant,  and  also  Mr. 
Durham,  have  introduced  tubes 
which  are  jointed  in  different 
ways,  so  that,  while  the  neck- 
plate  remains  fixed,  the  curve 
of  the  tube  can  adapt  itself  to 
the  trachea.  Mr.  Morrant 
Baker  has  met  the  difficulty  in 
another  way,  and  has  devised  a 
tube  which  is  made  of  India- 
rubber  spread  upon  fine  canvas 
(Fig.  174). 

The  tube  should  be  secured 
by  tapes  passed  round  the  neck, 
and  tied  behind.  The  edges 
of  the  wound  should  be  pro- 
tected against  the  pressure  and  irritation  of  the  tube  by  a  little 
cotton-wool,  or  a  piece  of  lint  spread  with  simple  cerate. 

The  great  danger  after  the  operation,  more  especially  in  chil- 
dren, is  extension  of  inflammation  to  the  lungs — bronchitis  or 
pneumonia.  To  prevent  this  must  be  our  chief  aim.  The  throat 
should  be  lightly  covered  with  flannel.  The  patient  should 
breathe  a  warm,  moist  atmosphere.  The  curtains  of  his  bed 
should  be  drawn,  and  a  kettle,  or  cans  of  hot  water,  giving  off 
steam,  should  be  placed  near  him,  so  as  to  create  a  sort  of  vapour- 
bath.  At  the  same  time,  his  strength  will  probably  require  to 
be  upheld  by  a  liberal  allowance  of  strong  beef-tea  and  soup.  In 
many  cases  stimulants  will  also  be  needed. 

If  the  operation  has  been  performed  for  a  temporary  cause,  the 
tube  should  be  removed  as  soon  as  possible,  and  the  wound 
allowed  to  heal.  But  in  cases  of  permanent  obstruction,  it  will 
be  necessary  for  the  patient  to  wear  a  tube  during  the  remainder 
of  his  life. 

Laryngotomy  and  laryngo-tracheotomy,  are,  as  I  have  said, 
safer  and  easier  operations  than  tracheotomy.  They  can,  more- 
over, be  performed  in  a  shorter  time;  and  they  are  generally 


Morrant  Baker's  tracheotomy 
tube. 


378  OPERATIONS. 

sufficient  to  meet  the  requirements  of  all  ordinary  cases,  for  in- 
flammatory action  commonly  stops  at  the  vocal  cords. 

Tracheotomy  is  especially  applicable  to  those  cases  in  which  a 
foreign  body  is  lodged  in  the  bronchi,  and  where  we  must  make  a 
large  opening  to  facilitate  its  expulsion ;  and  also  to  cases  of  croup 
and  diphtheria,  in  which  we  want  to  get  as  far  away  from  the 
larynx  as  possible,  in  the  hope  of  reaching  a  point  to  which  the 
inflammation  does  not  extend. 

It  is  one  of  the  vexed  questions  of  surgery,  whether  the  wind- 
pipe ought,  or  ought  not,  to  be  opened  in  cases  of  croup  and 
diphtheria.  The  operation  is  so  far  from  being  successful  that 
few  surgeons  would  venture  to  recommend  it,  except  as  a  last 
resource.  And  even  as  a  last  resource,  it  ought  not  to  be  prac- 
tised in  all  cases  indiscriminately.  If  the  face  has  a  peach- 
coloured  hue,  and  the  pulse  is  quick,  weak,  and  failing,  then  an 
operation  ought  not  to  be  undertaken.  But  if  the  colour  is  good, 
if  the  blood  is  still  well  aerated,  and  the  pulse  full,  strong,  and 
regular,  while  at  the  same  time  it  is  clear  that  the  disease  is 
making  progress,  and  will  ere  long  destroy  life,  then  tracheotomy 
may  be  proposed  with  some  slight  hope  of  success.  Even  if  it 
does  not  save  life,  the  surgeon  may  have  the  satisfaction  of 
knowing  that  death  by  asphyxia  has  been  averted,  and  that  the 
patient's  end  has  been  rendered  less  painful  and  distressing. 

XilGATURE  OF  .aRTERXES. 

Ligature  of  the  lingual  artery  has  been  practised  both  for  per- 
sistent bleeding  from  an  ulcerated  cancer  of  the  tongue,  and  also 
in  the  hope  of  starving  tumours  in  that  situation.  I  believe  the 
cases  are  very  rare  in  which  it  is  impossible  to  arrest  hsemorrhage 
from  the  tongue  at  the  bleeding  point ;  and,  although  cutting  off 
the  supply  of  blood  from  a  morbid  growth  may  have  some  tem- 
porary effect  on  its  nutrition,  yet  it  is  of  no  permanent  benefit. 
It  must  also  be  borne  in  mind  that  it  has  generally  been  in  cases 
of  malignant  disease  of  the  tongue  that  ligature  of  the  lingual 
artery  has  been  recommended,  and  in  such  cases  the  normal 
anatomy  of  the  parts  is  liable  to  be  disturbed  by  the  enlargement 
which  takes  place  in  the  submental  region  and  at  the  upper  part 
of  the  neck.  For  these  reasons,  therefore,  the  operation  is  one 
which,  as  a  general  rule,  cannot  be  recommended. 

If,  however,  the  surgeon  deems  it  necessary  to  tie  the  artery,  it 
may  be  reached  most  conveniently  near  its  origin,  where  it  lies 
just  above  the  greater  cornu  of  the  hyoid  bone,  and  before  it 
passes  beneath  the  hyo-glossus  muscle.  An  incision  should  be 
made,  almost  from  the  point  of  the  chin,  downwards  and  back- 
wards, to  a  little  below  the  greater  horn  of  the  hyoid  bone.    This 


LIGATURE  OF  AETERIES.  379 

incision  should  then  be  turned  and  carried  upwards,  almost  at  a 
right  angle,  to  near  the  angle  of  the  jaw.  The  flap,  when  dis- 
sected back,  will  correspond  nearly  with  the  digastric  triangle. 
The  posterior  border  of  the  subuaaxillary  gland  will  have  to  be 
held  aside.  This  will  bring  into  view  the  central  tendon  of  the 
digastric,  and  the  posterior  edge  of  the  mylo-hyoid  muscle ;  and 
the  hypo-glossal  nerve  with  a  vein  will  be  seen  lying  horizontally 
upon  the  hyo-glossus  muscle.  If,  then,  the  surgeon  feels  for  the 
posterior  margin  of  this  muscle,  he  will  find  the  lingual  artery 
lying  just  above  the  greater  cornu  of  the  hyoid  bone.  Perhaps 
he  may  have  to  divide  a  portion  of  the  muscle  before  he  will  be 
able  to  place  the  ligature. 

Ligature  of  the  common  carotid  artery  may  be  required  for 
a  wound,  or  for  an  aneurysm,  either  of  the  vessel  itself  or  of  one  of 
its  branches.  If  the  trunk  itself  is  wounded,  a  ligature  must  be 
put  upon  both  ends  of  the  vessel,  at  the  seat  of  injury. 

If  the  surgeon  can  select  his  own  situation,  he  generally  places 
the  ligature  either  immediately  above,  or  immediately  below,  the 
crossing  of  the  omo-hyoid  muscle. 

The  anterior  border  of  the  sterno-mastoid  muscle,  or  a  line 
drawn  from  the  sterno-clavicular  joint  to  the  depression  behind 
the  angle  of  the  jaw,  serves  as  a  guide  to  the  course  of  the  artery. 
Here  it  lies  upon  the  anterior  spinal  muscles,  having  the  sym- 
pathetic nerve  behind  it,  and  the  descendens  noni  in  front.  On 
its  outer  side  is  the  internal  jugular  vein,  and  between  the  vein 
and  the  artery,  and  behind  them  both,  is  placed  the  pneumogastric 
nerve.  The  vein,  artery,  and  nerve  are  all  included  in  a  common 
sheath,  though  each  has  its  own  compartment.  Occasionally,  the 
descendens  noni  is  found  in  the  same  sheath,  lying  in  front  of  the 
artery. 

An  incision  is  made  about  three  inches  long,  commencing 
opposite  the  upper  border  of  the  thyroid  cartilage,  and  carried 

Fig.  175. 


along  the  anterior  edge  of  the  sterno-mastoid  muscle.  After 
cutting  through  the  skin,  platysma,  and  superficial  fascia,  the 
sheath  of  the  vessels  comes  into  view.     This  must  be  carefully 


380  OPERATIONS. 

exposed  with  the  finger-nail  or  the  handle  of  the  scalpel,  and 
freed  from  the  branches  of  the  descendens  noni.  The  sheath 
should  then  be  lifted  with  a  forceps  at  the  point  where  the  liga- 
ture is  to  be  applied,  and  a  nick  made  in  it — the  flat  of  the  blade 
being  turned  towards  the  artery.  The  opening  in  the  sheath 
should  then  be  enlarged  on  a  director.  If  the  vein  overlaps  the 
artery,  as  it  sometimes  does,  it  must  be  held  back  with  a  re- 
tractor. The  pneumogastric  nerve  will  probably  be  drawn  aside 
along  with  it.  An  aneurysm  needle  (Fig.  175),  armed  with  a 
stout  ligature,  should  then  be  passed  cautiously  and  closely  round 
the  artery  from  without  inwards.  Sometimes  it  is  safer  and 
more  convenient  to  pass  the  needle  unarmed,  and  then  to  thread 
it,  and  withdraw  it.  In  this,  and  in  every  operation  of  the  same 
kind,  the  parts  should  be  disturbed  as  little  as  possible.  Before 
the  ligature  is  tied,  it  is  well  to  see  that  it  embraces  nothing  but 
the  artery,  and  that  pressure  upon  the  included  vessel  arrests  the 
haemorrhage,  or  controls  the  pulsation  in  the  aneurysm,  as  the 
case  may  be.  The  ligature  should  be  drawn  tight,  so  as  to  divide 
the  two  inner  coats  of  the  artery,  and  then  tied  in  a  reef-knot. 
One  end  should  be  cut  off,  and  the  other  left  hanging  out  of  the 
wound.  When  bleeding  has  quite  ceased,  the  edges  of  the  wound 
should  be  brought  together,  and  secured  by  strips  of  plaster. 
The  patient  must  be  kept  perfectly  quiet,  until  the  ligature  comes 
away.  This  will  probably  happen  in  the  course  of  ten  or  twelve 
days.  Or  the  surgeon  may  prefer  to  use  a  carbolized  catgut  liga- 
ture, and  to  cut  both  ends  off  short,  and  to  endeavour  to  heal  the 
wound  as  rapidly  as  possible  by  adhesive  inflammation. 

The.  pulsation  in  an  aneurysm,  which  has  ceased  as  soon  as  the 
ligature  was  applied,  sometimes  returns  when  the  collateral  cir- 
culation becomes  established,  and  then  again  gradually  disappears 
as  consolidation  takes  place  in  the  sac. 

Aneurysm  of  the  innominate  artery  has  been  treated  by  the 
ligature  of  the  subclavian  and  carotid  arteries,  either  simul- 
taneously, or  with  an  interval  of  time.  In  1865  Mr.  C.  Heath 
simultaneously  tied  the  subclavian  in  the  third  part  of  its  course 
and  the  common  carotid  for  an  aneurysm  in  this  situation.  The 
patient  was  much  relieved,  and  lived  for  two  years.  Though 
such  a  measure  of  success  is  very  gratifying,  yet,  looking  at  the 
whole  range  of  such  operations,  it  must,  I  think,  be  allowed  that, 
as  far  as  our  experience  has  yet  gone,  the  treatment  of  this  for- 
midable disease  belongs  to  the  physician  rather  than  to  the  sur- 
geon. More  can  be  done  by  medicine  and  diet,  to  prolong 
the  patient's  life,  and  to  make  it  tolerable,  than  by  operative 
surgery. 

Quite  recently  (May  1879)  Mr.  Barwell  has  communicated  to 


LIGATUEE   OF  ARTERIES.  381 

the  Royal  Medical  and  Chirurgical  Society  a  case  in  which 
he  ligatured  the  ri^ht  carotid  and  subclavian  arteries  for  the 
relief  of  an  aortic  aneurysm.  This  is  the  first  case  in  which 
such  a  proceeding  has  been  undertaken,  and  the  results  are 
encouraging. 

Ligature  of  the  subclavian  artery  has  been  performed  in  all 
the  three  parts  of  its  course,  though  the  results  which  have 
attended  the  operations  upon  the  first  and  second  portions  have 
scarcely  been  such  as  to  warrant  their  repetition. 

Ligature  of  the  subclavian  artery  in  the  first  part  of  its  course 
upon  the  left  side  is  almost  an  impracticable  operation,  on  account 
of  the  depth  at  which  the  vessel  lies,  and  the  important  parts 
by.  which  it  is  surrounded.  On  the  right  side  the  operation  is 
practicable,  but  it  has  never  been  performed  with  success.  Look- 
ing at  the  diflSculty  of  its  execution,  Sir  Wm.  Fergusson  says— 
"  Were  I  asked  to  state  which  I  thought  the  most  difficult  opera- 
tion in  surgery,  I  should  at  once  name  the  one  last  described" 
{i.e.,  ligature  of  the  subclavian  artery  on  the  tracheal  side  of  the 
scaleni  muscles).  While  Mr.  Erichsen,  having  regard  to  the 
principle  upon  which  it  is  based,  and  the  results  attained  by  it, 
says — "  While  this  operation  is  bad  in  principle,  it  is  most  un- 
fortunate in  practice.^'  It  is  not  necessary,  therefore,  that  I 
should  describe  the  mode  of  its  performance,  for  it  is  a  proceed- 
ing which  cannot  be  recommended.  The  distinguished  surgeon 
whom  I  have  just  quoted,  says  that,  in  his  opinion,  it  ought  cer- 
tainly "  to  be  banished  from  surgical  practice." 

Mr.  A.  F.  McGill,  of  Leeds,  has  cut  down  upon  the  left  sub- 
clavian artery  in  the  first  part  of  its  course,  and  applied  tem- 
porary pressure  by  means  of  a  torsion  forceps,  in  a  manner  which 
deserves  special  attention  ("  Med.-Chir.  Trans.,"  1878). 

Ligature  of  the  subclavian  artery  in  the  second  part  of  its 
course,  where  it  lies  between  the  scaleni  muscles,  has  been  prac- 
tised, and  with  success,  by  no  less  distinguished  a  surgeon  than 
Dupuytren.  Still  it  is  not  looked  upon  with  favour  at  the  pre- 
sent day ;  and  when  we  consider  that  the  scalenus  anticus  has  to 
be  divided,  upon  which  lies  the  phrenic  nerve,  and  at  the  inner 
margin  of  which  is  the  internal  jugular  vein,  and  that  many 
other  most  important  parts  are  situated  in  the  immediate  neigh- 
bourhood, we  shall  not  be  surprised  that  Dupuytren's  example 
has  been  but  seldom  followed. 

Ligature  of  the  subclavian  artery  in  the  third  part  of  its  course 
is  the  only  operation  upon  this  vessel  which  can  be  recommended. 
In  performing  this  operation  the  shoulders  should  be  lowered  as 
much  as  possible.  The  skin  should  then  be  evenly  drawn  down, 
and  an  incision  made  upon  the  clavicle,  from  the  anterior  border 


382  OPERATIONS. 

of  the  trapezius  to  the  posterior  edge  of  the  sterno-mastoid 
muscle.  The  platysma  myoides  and  the  fascia  of  the  neck  should 
then  be  divided  on  a  director.  The  external  jugular  vein  will  be 
seen  near  the  inner  part  of  the  wound,  and  must  be  held  aside, 
together  with  any  other  veins  that  may  traverse  the  space.  In  a 
similar  way  the  omo-hyoid  muscle  must  be  drawn  aside.  The 
various  parts  should  then  be  most  carefully  separated  by  means 
of  a  silver  probe,  until  the  outer  margin  of  the  scalenus  anticus 
is  felt.  This  will  serve  to  guide  the  surgeon's  finger  to  the 
first  rib,  and  the  artery  will  be  felt  passing  over  that  bone.  In 
order  to  avoid  the  vein,  the  aneurysm  needle  should  be  passed 
from  before  backwards,  and  the  surgeon  must  be  careful  not  to 
mistake  any  of  the  branches  of  the  brachial  plexus  for  the  artery, 
or  to  include  them  in  the  ligature. 

In  a  case  of  subclavian  aneurysm.  Professor  Spence  combined 
amputation  at  the  shoulder  with  the  distal  ligature  of  the  vessel, 
and  obtained  a  very  encouraging  measure  of  success. 

Ligature  of  the  axillary  artery. — The  axillary  artery  may  be 
tied  either  in  the  upper  or  in  the  lower  part  of  its  course.  Its 
central  portion  lies  so  deep,  is  surrounded  by  so  many  important 
nervous  trunks,  and  gives  off  so  many  branches,  that  its  deliga- 
tion  is  impracticable. 

The  artery  has  been  ligatured  in  the  upper  part  of  its  course; 
but  as,  before  it  can  be  exposed,  the  dissection  must  be  carried 
through  a  thick  muscle  and  the  costo-coracoid  membrane  divided, 
and  as  the  cephalic  and  the  axillary  veins  are  in  intimate  rela- 
tion with  it,  the  operation  should  not  be  undertaken  without  very 
special  reasons.  It  will  generally  be  preferable  to  tie  the  sub- 
clavian in  the  third  part  of  its  course. 

The  axillary  artery  may  be  secured  in  the  lower  part  of  its 
course  by  raising  the  arm  from  the  side,  and  making  an  incision 
in  the  axilla,  corresponding  to  the  head  of  the  humerus,  and  in  the 
line  of  the  great  vessels.  By  cautious  dissection  the  median  nerve 
and  the  axillary  vein  are  brought  into  view.  These  must  be  held 
aside  while  the  artery  is  separated  with  a  silver  probe,  and  a  liga- 
ture is  placed  round  it  in  the  usual  manner. 

When  considering  the  aneurysms  which  occur  about  the  root  of 
the  neck  and  the  axilla,  we  can  hardly  help  coming  to  the  conclu- 
sion that  there  are  but  few  of  them  which  can  be  successfully 
treated  by  the  ligature  of  arteries ;  and  that  if  surgery  is  ever 
to  be  able  to  cure  them  with  any  certainty,  it  must  be  by  some 
other  means.  Possibly  to  some  of  them  it  may  be  found  prac- 
ticable to  apply  pressure  in  the  way  that  has  lately  been  so  happily 
done  in  the  case  of  abdominal  aneurysms  (see  p.  199) ;  and,  indeed, 
Mr.  McGill's  operation  upon  the  left  subclavian,  to  which  I  have 


LIGATURE  OF  AETERIES.  383 

referred,  was  based  upon  this  principle.  Possibly  galvano-punc- 
ture  may  suflSce  to  cure  others;  while  the  well-known  case  in 
which  Mr.  C.  Moore  introduced  a  coil  of  iron  wire  into  a  thoracic 
aneurysm  may  suggest  the  means  of  dealing  with  others  ("  Med.- 
Chir.  Trans.,"  vol.  xlvii.). 

Ligature  of  the  hrachial  artery. — The  brachial  artery  is  gene- 
rally tied  at  the  middle  of  the  upper  arm.  In  this  situation  it 
lies  under  the  inner  edge  of  the  biceps,  covered  only  by  the  in- 
tegument and  fascia.  It  is  accompanied  by  its  two  venae  comites, 
and  at  this  point  it  is  crossed,  from  without  inwards,  by  the  median 
nerve.  It  will  here  be  found  in  close  relation  to  the  basilic 
vein,  the  ulnar  nerve,  and  the  inferior  profunda  artery. 

An  incision,  about  three  inches  long,  is  made  along  the  inner 
border  of  the  biceps,  great  care  being  taken  to  keep  close  to  the 
edge  of  the  muscle,  which  is  a  sure  guide  to  the  artery.  After 
the  skin  has  been  divided,  the  fascia  must  be  cautiously  slit  up 
on  a  director.  The  artery  with  its  vense  comites,  and  crossed  by 
the  median  nerve,  will  then  be  exposed  to  view.  The  nerve  must 
be  gently  drawn  aside  with  a  blunt  hook,  and  the  veins  carefully 
separated  from  the  artery;  after  which  the  ligature  is  passed 
round  the  vessel,  and  tied  in  the  ordinary  way. 

It  may  sometimes  be  necessary,  especially  in  traumatic  cases, 
to  tie  the  artery  at  the  bend  of  the  elbow.  Tlie  incision  must 
be  made  carefully  on  account  of  the  large  veins  in  this  situation, 
and  then  it  must  be  carried  through  the  strong  fascia  that 
spreads  out  from  the  tendon  of  the  biceps.  The  artery,  accom- 
panied by  its  venae  comites,  will  be  found  about  half  an  inch  to 
the  inner  side  of  the  tendon,  the  median  nerve  lying  on  its  ulnar 
aspect. 

Ligature  of  the  radial  artery. — It  is  often  necessary  to  tie  the 
radial  artery  at  the  wrist,  where  it  lies  beneath  the  integument 
and  deep  fascia,  between  the  tendons  of  the  supinator  longus  and 
the  flexor  carpi  radialis.  It  is  accompanied  by  its  vense  comites, 
but  in  this  situation  it  bears  no  immediate  relation  to  its  corre- 
sponding nerve. 

The  pulsation  in  the  artery  will  form  the  best  guide  to  its 
exact  situation.  If,  however,  an  anatomical  rule  is  wanted,  we 
may  say  that  in  an  adult  it  lies  half  an  inch  to  the  outer  side 
of  the  flexor  carpi  radialis.  An  incision,  about  two  inches  long, 
should  be  made  through  the  skin  and  superficial  fascia.  The 
deep  fascia  must  then  be  cautiously  divided,  or  slit  up  on  a 
director.  The  artery  must  be  separated  from  its  vense  comites 
with  the  point  of  the  scalpel,  or  with  the  finger-nail,  and  the 
ligature  passed  round  the  vessel. 

Ligature  of  the  ulnar  artery. — It  is  generally  in  wounds  of" 


384  OPERATIONS. 

the  paltn  that  the  ulnar  artery  requires  to  be  tied,  and  then  a 
ligature  may  conveniently  be  placed  round  it  just  above  the 
wrist.  In  this  situation  it  lies  between  the  innermost  tendon 
of  the  flexor  sublimis  digitorum  and  the  tendon  of  the  flexor 
carpi  ulnaris.     On  its  inner  side  it  has  the  ulnar  nerve. 

An  incision,  two  inches  in  length,  should  be  made  over  the 
artery,  a  little  to  the  outer  side  of  the  flexor  carpi  ulnaris.  When 
the  superficial  and  deep  fascia  have  been  divided,  the  vessel  and 
its  vense  comites  will  be  exposed.  In  this  case  it  is  important 
that  the  needle  should  be  passed  from  the  ulnar  to  the  radial 
side,  so  as  not  to  disturb  or  injure  the  nerve. 

As  I  have  already  said,  bleeding  from  the  radial,  the  ulnar, 
and  other  superficial  arteries  may  often  be  quickly  and  easily  con- 
trolled by  acupressure,  the  needle  being  passed  through  the 
tissues  on  one  side  of  the  vessel,  then  across  the  artery,  and  then 
again  through  the  tissues  on  the  other  side  (see  p.  52j. 

Ligature  of  the  external  iliac  artery. — The  course  of  the  ex- 
ternal iliac  artery  may  be  described  by  a  line  drawn  from  the 
left  side  of  the  umbilicus  to  a  point  midway  between  the  anterior 
superior  spine  of  the  ilium  and  the  symphysis  pubis.  It  lies 
along  the  inner  edge  of  the  psoas  muscle,  in  a  sheath  derived 
from  the  iliac  fascia.  Its  accompanying  vein  will  be  found 
behind  it,  and  a  little  to  its  inner  side.  It  is  overlaid  in  front 
by  the  peritoneum.  Near  its  termination  it  comes  into  relation 
with  the  spermatic  vessels  and  the  vas  deferens.  On  the  front 
and  inner  side  of  the  artery  are  a  number  of  lymphatic  glands 
with  their  vessels.  The  ligature  must  not  be  placed  too  near  the 
internal  iliac  at  the  upper  end,  or  the  epigastric  and  circumflex 
vessels  at  the  lower  end. 

The  incision  should  be  about  three  inches  long.  It  should 
begin  about  half  an  inch  above  and  to  the  outer  side  of  the  ex- 
ternal abdominal  ring,  and  be  carried  upwards  and  outwards, 
parallel  to  Poupart's  ligament.  When  the  aponeurosis  of  the 
external  oblique  muscle  has  been  fairly  exposed,  it  must  be 
divided  to  the  same  extent,  or  slit  up  on  a  director.  The  in- 
ternal oblique  and  transversalis  must  be  cut  through  in  the  same 
way,  but  with  even  greater  caution.  The  edges  of  the  wound 
should  then  be  retracted,  and  the  fascia  transversalis  scratched 
through  with  the  nail,  and  broken  down  with  the  finger.  The 
peritoneum  should  next  be  very  lightly  and  gently  raised,  and 
pushed  upwards,  until  the  vessel  can  be  reached.  An  opening 
should  then  be  made  in  the  sheath,  the  artery  carefully  sepa- 
rated from  the  vein,  and  the  aneurysm  needle  passed  from  within 
outwards.  The  wound  should  be  brought  together  with  sutures, 
and  pressure  made  upon  it  by  means  of  a  pad  and  bandage.     The 


LIGATURE  OF  ARTEEIES.  385 

patient  should  be  propped  up  in  bed,  so  as  to  relax  the  abdouiinal 
muscles. 

Before  the  operation  is  undertaken  the  rectum  should  be 
emptied,  and  the  pubes  shaved. 

Ligature  of  the  superficial  femoral  artery. — The  superficial 
femoral  artery  is  generally  tied  in  Scarpa's  triangle,  just  above 
the  point  where  it  is  crossed  by  the  sartorius  muscle.  It  is  here 
covered  only  by  the  integument  and  fascia  lata,  and  has  the 
superficial  femoral  vein  almost  immediately  behind  it. 

The  thigh  should  be  slightly  flexed  and  abducted,  before  the 
operation  is  commenced.  The  course  of  the  artery  may  be  ascer- 
tained by  its  pulsation,  or  by  a  line  drawn  from  the  middle  of 
Poupart's  ligament  to  the  inner  condyle  of  the  femur.  The  in- 
cision should  begin  about  three  inches  below  Poupart's  ligament, 
and  be  carried  down  the  limb  in  the  line  of  the  artery  for  the 
space  of  four  inches.  The  fascia  lata  should  be  divided  to  an 
equal  extent,  and  the  sartorius  drawn  a  little  outwards.  The 
sheath  of  the  vessel  sbould  then  be  raised  with  a  forceps  and 
opened,  the  flat  of  the  blade  being  turned  towards  the  artery. 
The  aneurysm  needle  should  be  passed  from  within  outwards, 
great  care  being  taken  to  avoid  injuring  the  vein. 

The  point  at  which  the  ligature  is  applied  should  be  about  five 
inches  below  Poupart's  ligament.  When  bleeding  has  ceased, 
the  edges  of  the  wound  should  be  brought  together  with  sutures 
and  strips  of  plaster.  The  limb  should  be  lightly  covered  with 
flannel,  or  enveloped  in  cotton-wool,  so  as  to  maintain  an  equable 
temperature,  and  diminish  the  chances  of  gangrene. 

Ligature  of  the  popliteal  artery  is  rarely  undertaken,  except 
for  wounds.  In  such  a  case,  the  opening  should  be  enlarged,  and 
the  bleeding  vessel  secured,  both  above  and  below  the  seat  of 
injury.  In  the  upper  part  of  the  popliteal  space,  the  tendon  of 
the  semi-membranosus  may  be  taken  as  a  guide  to  the  artery, 
and  the  incision  carried  along  its  outer  border.  In  this  situa- 
tion the  internal  popliteal  nerve,  and  the  popliteal  vein,  are  both 
superficial  to  the  artery,  and  a  little  to  its  outer  or  fibular  side. 

Ligature  of  the  tibial  arteries  in  the  fleshy  part  of  the  leg  is 
both  a  difficult  and  a  dangerous  operation,  and  one  which  ought 
not  to  be  undertaken  except  for  a  wound  of  the  vessel.  In  such 
a  case,  the  wound  should  be  enlarged,  and  a  ligature  placed  both 
above  and  below  the  seat  of  injury. 

The  posterior  tibial  artery  may  easily  be  tied  behind  the  inner 
malleolus.  Here  the  vessel  is  covered  only  by  the  integument 
and  by  the  deep  fascia,  which  ia  this  situation  is  unusually  thick 
and  dense,  forming  the  internal  annular  ligament.  A  semilunar 
incision,  about   two  inches  in  length,  with  its  concavity  turned 

C  C 


386  OPEEATIONS. 

towards  the  ankle,  should  be  made,  midway  between  the  heel 
and  the  inner  malleolus.  The  deep  fascia  should  then  be  cau- 
tiously divided  on  a  director,  the  artery  separated  from  its  venae 
comites,  and  the  aneurysm  needle  passed  from  the  heel  towards 
the  malleolus,  so  as  to  avoid  the  nerve,  which  lies  between  the 
artery  and  the  tendo  Achillis. 

Ligature  of  the  anterior  tibial  artery. — The  anterior  tibial 
artery  may  be  tied  in  the  lower  third  of  the  leg,  where  it  lies 
between  the  tendons  of  the  tibialis  anticus  and  the  extensor 
proprius  pollicis.  In  this  situation  it  is  covered  only  by  the 
integument  and  deep  fascia.  If  the  pulsation  of  the  artery 
cannot  be  felt,  the  incision  should  be  made  half  an  inch  outside 
the  crest  of  the  tibia,  and  in  rather  an  oblique  direction  from 
within  outwards.  The  tendons  should  be  separated,  and  then  the 
artery  will  be  seen,  accompanied  by  its  venae  comites,  and  having 
the  nerve  in  front  of  it. 

Ligature  of  the  anterior  tibial  artery  in  the  upper  two-thirds 
of  its  course  is  a  more  difficult  operation.  Here  the  vessel  lies  upon 
the  interosseous  membrane,  on  the  outer  side  of  the  tibialis 
anticus  muscle.  The  surgeon  should  make  an  incision  down- 
wards and  outwards  from  the  crest  of  the  tibia,  and  lay  open  the 
first  inter-muscular  septum  that  he  reaches.  Here  he  will  find 
the  anterior  tibial  nerve,  and,  beneath  it,  the  artery. 

The  arteria  dorsalis  pedis  may  be  secured  on  the  instep, 
where  it  lies  between  the  tendon  of  the  extensor  proprius  pollicis 
and  the  innermost  tendon  of  the  extensor  brevis  digitorum.  It  is 
here  covered  only  by  the  integument  and  deep  fascia.  It  is  rarely, 
however,  that  it  requires  to  be  tied,  for  bleeding  from  it  can 
generally  be  controlled  by  acupressure,  or  by  a  pad  and  bandage. 

EXCXSIOZr  OF  JOIITTS. 

When  a  joint  connected  with  the  extremities  has  become  hope- 
lessly diseased,  or  has  been  severely  injured,  it  is  the  practice  of 
modern  surgeons  to  consider  whether  the  disease  cannot  be  taken 
away  without  removing  the  entire  limb.  Excision — or,  as  it  is 
sometimes  termed,  resection — has  been  performed  upon  almost 
every  joint  of  the  upper  and  lower  extremities,  and  the  results  of 
many  of  these  operations  are  so  satisfactory  that  they  have  taken 
an  established  place  in  practice. 

JExcision  of  the  shoulder -joint. — In  this,  as  in  every  operation 
of  the  kind  undertaken  for  long-standing  disease  of  the  bone  or 
for  injury  from  direct  violence,  it  is  well  to  arrange  the  incisions 
so  as  to  fall  in  with  the  existing  sinuses  or  lacerations.  The  line 
of  incision  may  take  the  shape  of  a  T,  or  an  L,  or  a  U,  or  any 
other  figure  suited  to  the  peculiarities  of  the  case.     The  incision 


EXCISION  OF  JOINTS.  387 

must  be  carried  through  the  deltoid  muscle,  and  the  flaps  dis- 
sected bacls,  so  as  to  expose  the  joint.  In  a  case  of  chronic 
diseasej  the  capsule  and  tendons  will  probably  be  more  or  Itss 
destroyed ;  a  few  touches  of  the  knife  will  suffice  to  divide  them, 
and  there  will  be  no  difficulty  in  turning  out  the  head  of  the 
humerus.  The  diseased  portion  must  be  cut  off  with  the  saw, 
care  being  taken  to  remove  as  little  as  possible  of  the  healthy 
bone.  If  the  glenoid  cavity  is  at  all  affected,  the  diseased  bone 
should  be  scooped  out  with  the  gouge.  When  this  has  to  be  done, 
it  indicates  that  the  morbid  action  is  extensive,  and  accord- 
ingly in  these  cases  the  prognosis  is  less  favourable. 

The  flaps  should  be  brought  together  by  a  few  stitches,  and 
the  arm  well  supported  in  a  sling,  and  laid  on  a  pillow. 

JExcision  of  tlie  elbow  may  be  performed  either  by  a  single 
longitudinal  incision,  or  by  one  in  the  shape  of  an  H  or  a  T ; 
probably  the  first  is  the  best.  In  arranging  his  incisions,  as  well 
as  in  carrying  out  the  operation,  the  surgeon  must  bear  in  mind 
the  position  of  the  ulnar  nerve,  which  passes  round  the  internal 
condyle  of  the  humerus.  When  the  flaps  have  been  dissected 
back,  the  arm  should  be  forcibly  bent.  The  lateral  ligaments 
may  then  be  easily  divided,  and  the  joint  exposed.  The 
articular  ends  of  the  bones  should  next  be  removed  with  the 
saw,  or  with  bone-pliers.  If  any  points  of  disease  present  them- 
selves on  the  sawn  surfaces,  they  must  be  scooped  out  with  the 
gouge.  If  the  dissection  is  carried  on  close  to  the  bone,  the 
ulnar  nerve  ought  not  to  be  seen.  The  capillary  haemorrhage  is 
sometimes  very  troublesome  after  this  excision.  In  a  case  on 
which  I  operated  there  was  great  difficulty  in  arresting  the  flow 
of  blood.  The  patient,  a  strumous  boy,  was  much  reduced  by  it ; 
but  he  ultimately  made  a  good  recovery.  When  all  bleeding  has 
ceased,  the  edges  of  the  wound  should  be  drawn  together  with 
sutures,  and  the  arm  extended  on  a  splint,  or  simply  laid  on  a 
pillow.  Mr.  Maunder  lays  great  stress  upon  the  importance  of 
preserving  those  fibres  of  the  triceps  which  are  inserted  into  the 
fascia  of  the  forearm,  especially  that  which  covers  the  anconeus. 
Upon  this,  he  says,  it  depends  whether  the  patient  retains  the 
power  of  extension  or  not. 

In  both  of  these  operations  upon  the  upper  extremity  what  we 
desire  is  ligamentous  union,  and  not  bony  ankylosis.  Therefore, 
after  three  weeks  or  a  month,  when  granulation  and  cicatrization 
are  complete,  the  surgeon  should  begin  to  make  a  little  passive 
motion,  and  the  patient  should  be  encouraged  to  use  his  arm. 

Excision  of  the  tvrist  is  an  operation  which  cannot  be  said  to 
have  taken  the  same  established  place  in  surgery  as  many  other 
proceedings  of  the  same  kind.     The  complex  nature  of  the  joint, 

c  c  2 


388  OPEEATIONS. 

and  the  number  of  tendons  which  pass  over  it,  mate  the  operation  a 
difficult  one ;  and  when  the  diseased  bone  has  been  removed,  it  is 
only  too  probable  that  the  hand  and  arm  which  are  left  will  be  of 
little  or  no  use  to  the  patient.  If  the  operation  is  undertaken  at 
all,  the  carpus  may  be  reached  by  a  semicircular  flap  on  the 
dorsal  aspect,  and  the  extensor  tendons  held  aside  so  as  to  ex- 
pose the  joint.  Or  the  surgeon  may  prefer  to  make  two  lateral 
incisions,  and  to  remove  the  joint  in  the  way  recommended  by 
Mr.  Lister.  In  the  subsequent  treatment  of  the  case  his  splint 
should  be  used,  so  as  to  support  the  hand,  and  to  maintain  the 
opposition  between  the  thumb  and  the  fingers  {Lancet,  March 
25,  1865). 

Excision  of  the  Mp-joint. — In  some  cases  of  chronic  disease  or 
gunshot  injury  the  head  of  the  femur  may  be  excised  with  ad- 
vantage (see  p.  183). 

A  longitudinal  incision  should  be  made  over  the  great  trochan- 
ter. If  need  be,  it  may  be  converted  into  a  T.  Maunder  recom- 
mends a  semilunar  incision  round  the  great  trochanter.  The 
dissection  should  then  be  carried  on  until  the  flaps  can  be  drawn 
back,  and  the  articulation  exposed.  When  the  ligaments  have 
been  divided,  the  surgeon  should  cut  close  to  the  bone,  remem- 
bering that  the  sciatic  nerve  lies  just  behind  the  joint,  and  the 
anterior  crural  nerve  and  the  femoral  artery  in  front  of  it.  The 
leg  should  then  be  strongly  adducted  or  rotated,  and  pushed  up- 
wards, so  as  to  force  the  head  of  the  femur  out  of  the  wound. 
The  diseased  portion  may  then  be  removed  with  the  saw.  The 
chain-saw,  which  enables  the  surgeon  to  cut  from  within  out- 
wards, is  very  applicable  to  this  operation.  If  any  part  of  the 
acetabulum  is  carious,  it  should  be  taken  away  with  the  gouge, 
p.     ^„„  The  leg  should  be  maintained 

^'        '  in  the  extended  position  by 

means  of  a  long  splint.  Op- 
posite the  seat  of  operation 
the  splint  should  be  inter- 
rupted, the  continuity  being 
kept  up  only  by  an  iron  bar 
in  the  way  represented  in 
Fig.  176,  so  as  to  allow  the 
wound  to  be  dressed,  without 
disturbing  the  position  of  the 


"~^ 


^ 


Interrupted  long  splint.  li'^^-     When  the  cicatrix  has 

healed,  and  the  tissues  have 
become  consolidated,  the  patient  may  be  permitted  to  walk  about 
with  crutches. 

Excision  of  the  Tcnee  is  an  operation  which  has  been  revived  of 


EXCISION  OF  JOINTS. 


389 


late  years ;  and  it  bids  fair  to  become  the  established  rule  of  prac- 
tice in  certain  cases  of  disease  or  injury  of  the  knee-joint. 

A  simple  transverse  incision  should  be  made  across  the  joint  im- 
mediately below  the  patella.  If  this  does  not  give  space  enough, 
it  may  be  converted  into  an  H  incision.  The  flaps  of  skin  are 
then  raised  and  turned  back.  The  ligament  of  the  patella  is 
divided,  and  the  bone  dissected  away.  If  the  surgeon  wishes  to 
retain  the  patella,  it  may  be  raised  with  the  upper  flap.  The 
leg  should  then  be  strongly  bent,  the  lateral  and  crucial  ligaments 
divided,  the  ends  of  the  bones  cleared  for  the  saw,  and  the  interior 
of  the  joint  exposed.  The  saw  should  then  be  applied  to  the 
femur,  and  a  portion  of  the  articular  extremity  removed.  A 
thin  slice  is  next  to  be  taken  from  the  upper  end  of  the  tibia. 
In  using  the  saw,  the  surgeon  must  exercise  caution,  remembering 
that  the  popliteal  vessels  lie  immediately  behind  the  bone.  The 
limb  should  then  be  extended,  in  order  to  see  whether  the  bones 
come  well  together.  Perhaps  the  saw  may  have  to  be  used  again. 
If  the  position  is  good,  and  the  bleeding  has  ceased,  the  skin  should 
be  united  by  sutures,  and  the  leg  extended  on  a  splint.  That 
which  is  generally  used  in  these  cases  is  a  j\r*Intyre's  splint,  laid 
straight,  and  cut  down  at  the  sides,  opposite  the  seat  of  operation, 
so  as  to  allow  the  wound  to  be  dressed  with  ease. 

The  time  during  which  the  patient  will  have  to  be  kept  in  bed 
after  this  operation  varies  extremely.  But  the  surgeon  will 
generally  have  reason  to  be  satisfied  if  his  patient  is  able  to  get 
up  at  the  end  of  two  months,  and  walk  about  on  crutches,  with 


Fig.  178. 


the  leg  supported  by  a  plaster  of  Paris,  gutta-percha,  or  light 
wooden   splint.      What    we    desire    in    these    cases  is  bony  or 


390  OPERATIONS. 

fibrous  ankylosis,  and  therefore  no  attempt  should  be  made  to 
flex  the  limb.  It  is  quite  possible,  however,  that  in  course  of 
time  the  patient  may  get  a  little  movement  at  the  knee.  But, 
whether  this  is  the  case  or  not,  he  will  probably  have  a  useful 
and  serviceable  limb.  Of  course  it  will  be  a  little  shorter  than 
its  fellow,  and  it  will  be  necessary  for  the  patient  always  to  wear 
a  high-heeled  boot. 

The  accompanying  illustrations  are  taken  from  photographs  of 
a  case  upon  which  Mr.  Bowman  operated  in  King's  College 
Hospital,  when  I  was  his  dresser.  Fig.  177  shows  the  distorted 
condition  of  the  left  leg  at  the  time  the  excision  was  performed. 
Fig.  178  represents  the  state  of  the  limb  nine  months  afterwards. 

There  has  been  much  discussion  of  late  years  with  regard  to 
the  relative  value  of  excision  and  amputation  for  diseases  and 
injuries  of  the  knee-joint.  Those  to  whom  we  are  most  indebted 
for  bringing  excision  to  the  notice  of  the  profession  have  not 
unnaturally  been  inclined  to  regard  it  with  rather  too  favourable 
an  eye;  while  others  have  been  unjustly  prejudiced  against  it. 
Perhaps  the  time  has  hardly  yet  come  for  striking  a  balance 
between  these  two  operations,  and  assigning  to  each  its  proper 
place  in  surgery.  As  no  one  has  been  at  more  pains  to 
collect  statistics  on  this  subject  than  Mr.  Bryant,  or  has  analysed 
them  more  carefully,  I  shall  quote  one  or  two  sentences  from  the 
general  conclusions  at  which  he  has  arrived.  In  these  he 
touches  upon  some  very  important  points — namely,  the  cases  to 
which  excision  is  applicable,  and  those  to  which  it  is  not,  and 
also  the  relative  mortality  after  the  two  operations. 

"  It  would  thus  appear  that  it  is  in  young  adult  life  that  ex- 
cisions, although  always  more  fatal  than  amputation,  are  the 
most  justifiable ;  that  in  childhood  they  are  far  too  dangerous ;  in 
patients  past  middle  age  all  admit  their  inapplicability.  And  yet 
it  must  be  admitted  that  excision  of  the  knee-joint  is  a  good 
operation  ;  that,  when  successful,  a  good,  useful  limb  is  given — a 
far  better  limb  than  can  be  given  after  amputation.  Nevertheless, 
the  truth  must  be  recognised  that  the  operation  is,  as  hitherto 
practised,  a  far  more  fatal  operation  than  amputation ;  and  yet 
it  may  with  confidence  be  asserted  that  the  cases  in  which  ampu- 
tation has  been  performed  are,  as  a  rule,  far  more  severe  than 
those  in  which  excision  has  been  practised"  ("  Surgery,"  p.  862), 

Excision  of  the  anhle-joint. — When  the  articular  surfaces  of 
the  astragalus  and  the  malleoli  are  diseased,  while  the  calcaneum 
and  the  other  bones  of  the  tarsus  are  sound,  the  surgeon  may 
undertake  excision  of  the  ankle-joint  with  good  hope  of  curing 
his  patient.  This  operation  was  first  performed  by  Mr.  Hancock. 

The  leg  should  be  laid  on  its  inner  side,  and  an  L-shaped  incision 


AMPUTATIONS. 


391 


Fig.  179. 


Foot  after  excision  of  the 
ankle. 


made  over  the  outside  of  the  joint.     By  this  means  the  external 

malleolus  may  he  reached,  and  nipped  off.  The  leg  is  then  turned 

over,  and  a  similar  incision  made 

over  the  inside  of  the  ankle.    The 

tendons  must  be  carefully   held 

aside,   together  with  the  artery 

and  nerve.     The  internal  lateral 

ligaments   must    be    freed,    and 

then  the  internal  malleolus  may 

be  cut  off.      If  now  the  foot  is 

forcibly    turned    outwards,    the 

lower  end  of  the  tibia  and  the 

upper  surface  of  the  astragalus 

will  present  themselves   at    the 

inner  wound ;    and   the  surgeon 

can  deal  with  them  as  he  thinks 

best  by  means  of  a  fine  saw  or 

cutting-pliers. 

Fig.  179  was  drawn  from  a  girl,  aged  nine,  upon  whom  Mr. 
Barwell  had  performed  excision  of  the  ankle  three  months 
previously. 

I  have  already  mentioned  that  when  the  astragalus  is 
dislocated  it  may  be  removed,  and  still  the  patient  may  retain  a 
very  useful  foot  (see  p.  193).  If  the  astragalus,  which  plays  such 
an  important  part  in  the  mechanism  of  the  foot,  can  be  taken  away 
without  serious  injury  to  the  patient,  it  is  not  surprising  that  other 
bones  of  the  tarsus  can  in  like  manner  be  dispensed  with.  There 
is  hardly  one  of  the  numerous  bones  of  the  foot  Avhich  has  not 
been  separately  excised.  This  is  one  of  the  advantages  which  we 
owe  to  what  Sir  Wm.  Fergusson  has  happily  termed  "  conservative 
surgery."  When  disease  is  limited  to  one  or  two  bones,  surgeons 
are  very  unwilling  to  remove  the  whole,  or  the  greater  part,  of  the 
foot.  They  content  themselves  with  excising  the  affected  bones, 
or  even  with  merely  gouging  out  the  dead  tissue,  and  rely  upon 
Nature  to  repair  the  gap  thus  made.  In  this  way,  the  calcaneum, 
the  scaphoid,  or  the  cuboid  may  be  separately  dealt  with  ;  and 
it  is  remarkable  what  a  useful  foot  is  often  left  after  the  removal 
of  even  an  important  bone. 

AXVIPUTiLTIOIirS. 

Amputations  may  be  performed  in  two  ways,  either  by  the 
circular  method,  or  by  flaps.  In  the  former  case  the  knife  is 
carried  evenly  round  the  limb.  This  is  repeated  three  or  four 
times,  until  the  whole  of  the  tissues  are  divided — an  assistant, 
meanwhile,  drawing  the  tissues  equally  and  steadily  upwards; 


392  OPERATIONS. 

so  that,  wlien  the  parts  are  relaxed,  the  sawn  end  of  the  bone 
will  be  seen  at  the  apex  of  a  hollow  cone  formed  by  the  muscles 
and  skin. 

The  flap  operation  is  performed  by  making  a  couple  of  flaps 
from  the  opposite  sides  of  the  limb.  Sometimes  they  are  of  equal 
length ;  sometimes  one  is  longer  than  the  other ;  sometimes  they 
are  made  by  cutting  from  wdthout  inwards;  sometimes  by  trans- 
fixing the  limb,  and  cutting  from  within  outwards.  Sometimes 
the  flaps  consist  merely  of  the  skin,  at  other  times  they  include 
the  whole  thickness  of  the  soft  tissues. 

Speaking  generally,  the  advantages  of  the  circular  operation 
are  these : — That  it  is  easily  performed,  and  requires  but  little 
skill  or  practice  ;  that  the  vessels  are  cut  transversely,  whereas  in 
the  flap  operation  they  are  divided  obliquely;  and  that  the 
resulting  stump  is  generally  satisfactory. 

The  advantages  of  the  flap  operation  are — That  the  surgeon 
can  take  the  flap  from  any  point  that  he  likes,  and  so  make  the 
most  of  the  sound  parts ;  that  the  sides  of  the  wound  come 
together  more  accurately,  and  unite  more  readily ;  and  that  the 
operation  itself  can  be  performed  in  a  shorter  time. 

The  late  Mr.  Teale,  of  Leeds,  introduced  a  modification  of  the 
flap  operation,  which  has  special  advantages  : — 

He  directs  that  a  rectangular  flap,  equal  in  length  and  breadth 
to  one-half  the  circumference  of  the  limb  at  the  seat  of  operation, 
should  be  taken  from  the  extensor  side ;  and  that  a  short  rectan- 
gular flap,  equal  only  to  a  quarter  of  the  length  of  the  other, 
should  be  taken  from  the  flexor  side.  The  advantages  of  this 
method  are  said  to  be  that  the  principal  vessels  and  nerves  are 
not  included  in  the  flap  which  forms  the  bearing-point  of  the 
stump ;  that  the  flap  covers  the  ends  of  the  bones  in  such  a  way 
as  to  close  them  at  an  early  date;  that  the  cicatrix  is  drawn  well 
up  above  the  extremity  of  the  stump,  and  yet  tension  is  prevented 
by  the  great  length  of  the  flap. 

A  mixed  form  of  operation  has  come  into  use  of  late  years,  and 
consists  in  taking  the  flaps  from  the  skin  alone,  and  then  dividing 
the  muscles  by  circular  incisions. 

Every  amputation  should  be  performed  as  far  from  the  trunk 
as  the  circumstances  of  the  case  will  allow.  The  mortality  in- 
creases in  direct  proportion  as  we  ascend  the  limbs. 

Before  any  of  these  operations  are  commenced,  Esmarch's  ban- 
dage should  be  applied,  and  the  limb  raised,  so  that  the  blood 
may  be  driven  out  of  the  tissues  (see  p.  365).  If  this  cannot 
be  done,  the  main  artery  should  be  compressed  during  the  opera- 
tion, either  by  the  fingers  of  an  assistant  or  by  a  tourniquet. 

Amputation  of  the  finger. — When  the  last  phalanx  is  necrosed. 


AMPUTATIONS.  393 

it  may  often,  as  we  have  elsewhere  explained,  he  removed  hy 
lateral  incisions.  In  this  way  the  pulp  and  the  nail  are  left,  and 
will  form  a  very  useful  point  to  the  finger  (see  p.  106). 

When  it  is  necessary  to  amputate  either  of  the  last  two 
phalanges,  the  finger  should  he  strongly  bent,  and  a  transverse  in- 
cision made  on  the  extensor  side,  a  little  below  the  highest  point 
of  the  flexure ;  the  lateral  ligaments  should  be  divided,  the  joint 
opened,  and  the  flap  taken  from  the  palmar  surface.  Or  the 
palmar  flap  may  he  made  hy  transfixion,  and  the  joint  opened 
afterwards,  either  from  its  palmar  or  dorsal  aspect. 

Amputation  at  the  metacarpo-phalangeal  joint  may  be  best 
performed  by  the  oval  method.  The  point  of  the  knife  is  placed 
on  the  hack  of  the  metacarpal  bone,  about  half  an  inch  above  its 
head,  and  drawn  obliquely  downwards  to  the  middle  of  the  inter- 
digital  web.  It  is  then  carried  across  the  fold,  which  separates 
the  finger  from  the  palm,  and  brought  up  through  the  web  on 
the  other  side,  to  the  spot  where  it  commenced.  The  lateral 
ligaments  must  next  be  divided,  and  the  disarticulation  completed. 
The  head  of  the  metacarpal  bone  should  then  be  removed  with 
bone  pliers,  and  the  edges  of  the  wound  brought  together.  The 
hand  should  be  laid  on  a  splint,  the  wound  covered  with  a  suitable 
dressing,  and  the  finger-ends  drawn  together,  and  fixed  by  means 
of  a  strip  of  plaster.  In  labouring  people,  to  whom  the  breadth  of 
the  palm  is  more  important  than  elegance  of  shape,  it  may  some- 
times be  well  to  leave  the  head  of  the  metacarpal  bone.  In  this 
case,  however,  the  incision  must  be  carried  a  little  further  for- 
ward on  the  flexor  side  of  the  finger,  so  as  to  form  a  sufficient 
flap. 

The  thumb  may  he  amputated  either  by  an  oval  incision,  be- 
ginning at  the  carpo-metacarpal  joint,  passing  round  the  web, 
and  returning  to  the  same  point  again ;  or  an  incision  may  be 
made  along  the  dorsal  aspect,  from  the  carpo-metacarpal  articu- 
lation to  the  middle  of  the  web  ;  the  ball  of  the  thumb  may  then 
be  transfixed,  and  a  flap  made  by  cutting  from  within  outwards. 
In  any  case,  it  is  better,  if  possible,  not  to  open  the  carpo-meta- 
carpal joint,  but  to  cut  the  bone  through  near  its  base.  When 
the  metacarpal  bone  of  the  thumb  is  necrosed,  it  may  be  exposed 
by  direct  incision,  the  disease  taken  away,  and  the  phalanges 
left.  In  dealing  with  the  thumb,  it  is  of  great  importance  to 
leave  as  much  as  possible,  to  serve  as  an  opponent  to  the  fingers. 

Amputation  at  the  tcrist  should  be  performed  thus  : — An  assis- 
tant should  grasp  the  arm  and  draw  the  tissues  well  up.  A  semi- 
lunar incision,  with  the  convexity  downwards,  is  then  made  across 
the  back  of  the  wrist.  The  flap  is  raised,  the  tendons  and 
ligaments  arc  divided,  and  the  joint  is  opened  from  its  dorsal 


394 


OPERATIONS. 


aspect.  The  knife  is  then  carried  through,  and  a  second  flap  is 
taken  from  the  pahu.  The  styloid  processes  may  require  to  be 
cut  off,  or  the  articular  surfaces  of  the  bones  removed,  before  the 
flaps  are  brought  together. 

Amputation  of  the  forearm  may  be  performed  either  by  a 
circular,  or  by  a  flap  operation. 

In  the  circular  operation  the  tissues  of  the  limb  throughout 
its  whole  circumference  are  to  be  drawn  evenly  upwards  by  an 
assistant.  The  surgeon  then  makes  a  circular  incision  round  the 
limb  down  to  the  fascia.  The  skin  is  next  drawn  as  much  farther 
up  as  possible.  A  second  circular  incision  is  made  through  the 
muscles,  immediately  below  the  line  of  the  skin.  The  bones  are 
then  cleared,  and  the  saw  applied  to  both  at  once. 

Or  a  flap  operation  may  be  performed.  In  this  proceeding  the 
hand  should  be  held  midway  between  pronation  and  supination, 
and  then  two  equal  flaps  should  be  made  by  transfixion,  one  from 
the  extensor,  and  the  other  from  the  flexor  side.  Or  Mr.  Teale''s 
method  may  be  adopted,  and  a  long  rectangular  flap  may  be 
taken  from  the  extensor  side,  and  brought  over  to  meet  a  short 
one  on  the  flexor  side. 

In  dressing  the  stump  which  is  left  after  such  an  amputation 
as  this,  either  in  the  upper  or  lower  extremity,  the-  surgeon  may 
take  strips  of  lint  of  sufficient  length,  and  fold  them  over  the  end 
of  the  stump  in  a  longitudinal  direction,  and  at  an  angle  with 
one  another,  until  the  whole  surface  is  covered  (Fig.  180) ;  or  he 
may  cut  out  a  piece  of  lint  in  the  shape  of  a  Maltese  cross,  and 


Fig.  180. 


Fig.  181. 


Dressings  for  a  stump. 

lay  its  ceTitral  portion  upon  the  end  of  the  stump,  while  he  folds 
down  the  corners  (Fig.  181).  In  either  case  the  dressings 
should  be  secured  by  a  few  circular  turns  of  a  roller  round  the 
limb  in  the  manner  represented  in  Fig.  184. 

Amputation  of  the  upper  arm  is  usually  best  performed  by  a 
couple  of  lateral  flaps  made  by  transfixion.  But  if  the  limb  is 
very  muscular,  a  better  result  may,  perhaps,  be  obtained  by  a 


AMPUTATIONS. 


395 


combination  of  the  flap  and  the  circular  methods.    Two  skin-flaps 
may  be  made  by  dissecting  from  without  inwards,  and  then  the 
muscles   may   be   divided    by   a  circular 
sweep  of  the  knife. 

Fig.  182  represents  the  stump,  three 
years  after  operation,  in  a  middle-aged 
woman,  whose  arm  I  amputated  on 
account  of  injuries  received  by  a  railway 
accident. 

Amputation  at  the  shoulder- joint  may 
be  performed  either  by  transfixion,  or  by 
cutting  from  without  inwards. 

If  the  method  by  transfixion  is  pre- 
ferred, the  arm  should  be  raised  from  the 
side,  and  then  the  knife  should  be  passed 
from  a  point  a  little  in  front  of  tlie 
acromion  to  the  posterior  margin  of  the 
axilla,  and  carried  downwards,  so  as  to 
include  nearly  the  whole  of  the  deltoid 
muscle  in  the  flap.  The  capsule  of  the 
joint  is  next  to  be  opened,  the  tendons 
and  ligaments  divided,  the  knife  carried 
over  the  head  of  the  bone  and  down  the 
neck,  and  then  made  to  cut  its  way  out, 
leaving  an  inner  flap  about  three  inches 

in  length.  Before  the  inner  flap  is  cut,  an  assistant  should 
grasp  the  whole  thickness  of  the  soft  tissues  which  will  compose 
it,  so  as  to  control  the  artery,  and  prevent  haemorrhage,  when  it 
is  divided. 

If  the  other  method  is  adopted,  an  outer  flap,  of  the  same  size 
and  shape  as  in  the  preceding  case,  should  be  made  by  cutting 
from  without  inwards.  The  dissection  must  then  be  carried  on 
underneath  this  flap,  until  it  can  be  turned  back  so  as  to  expose 
the  joint.  The  other  steps  of  the  operation  are  the  same  as  those 
which  have  been  already  described. 

The  oval  method,  commonly  called  Larrey's  operation,  is  well 
suited  to  some  cases.  It  is  thus  described  by  Eriehsen : — "  Larrey 
commenced  his  operation  by  a  vertical  incision  down  to  the 
bone,  about  two  inches  in  length,  commencing  immediately  below 
the  acromion  process.  From  the  end  of  this  he  made  a  curved 
incision  on  each  side,  reaching  to  the  corresponding  fold  of  the 
axilla.  The  two  flaps  thus  formed  were  dissected  up,  and  the 
head  of  the  bone  disarticulated.  The  knife  was  then  passed  in- 
ternally to  the  head  of  the  bone,  and  carried  downwards,  while 
an  assistant  followed  it  with  his  hands  to  compress  the  axillary 


Stump  after  amputation 
through  the  humerus. 


396  OPERATIONS. 

artery.  The  operation  was  completed  by  dividing  the  tissues  in 
the  axilla  between  the  ends  of  the  two  curved  incisions  previously 
made  to  its  borders." 

Amputation  at  the  hip-joint  is  performed  by  transfixion,  a  long 
flap  being  taken  from  the  front  of  the  thigh,  and  a  short  posterior 
one  from  the  gluteal  region.  The  knife  should  be  passed  obliquely 
through  the  thigh  immediately  in  front  of  the  joint,  entering  a 
little  below  the  anterior  superior  spine  of  the  ilium,  and  emerging 
just  above  the  tuber  ischii,  or  vice  versa.  As  the  knife  cuts  its 
way  outwards,  the  fingers  of  an  assistant  should  be  introduced 
immediately  behind  it,  so  as  to  grasp  the  whole  breadth  of  the 
flap,  and  compress  the  femoral  artery.  Tlie  capsule  is  then  to  be 
opened,  the  ligaments  divided,  the  knife  carried  round  the  head 
of  the  bone,  and  the  posterior  flap  fashioned.  In  order  to  facili- 
tate the  operation,  it  ought  to  be  the  sole  duty  of  an  assistant  to 
move  the  limb  in  such  a  way  as  to  stretch  the  capsule  and  liga- 
ments, make  the  head  prominent,  and  raise  it  out  of  the  socket. 
Before  undertaking  an  amputation  at  the  hip-joint,  the  surgeon 
should  restrain  the  circulation  through  the  leg  by  applying 
Lister's  compressor  over  the  abdominal  aorta. 

Amputation  of  the  thigh  may  be  performed  either  through  the 
trochanters,  or  in  the  middle  of  the  thigh,  or  above  the  knee. 

The  first  step  is  to  apply  a  tourniquet  to  the  femoral  artery  in 
Scarpa's  triangle.     The   tourniquet  which  is  generally  used  for 
this  purpose  (Petit's)  consists  of  a  pad  which 
Fig.  183.  is  placed  over  the  artery,  a  strap  of  webbing 

which  passes  round  the  limb,  and  a  screw 
which  acts  upon  the  strap  and  tightens  it 
(Fig.  183).  By  turning  the  screw  the  two 
plates  over  which  the  strap  passes  are  sepa- 
rated, the  strap  is  put  upon  the  stretch,  and 
pressure  is  made  upon  the  pad.  The  pad 
should  be  placed  as  nearly  as  possible  opposite 
the  screw,  and  the  buckle  should  be  adjusted 
in  such  a  manner  as  not  to  interfere  with  the 
working  of  the  instrument.  Instead  of  the 
pad  which  is  usually  sold  with  the  tourni- 
quet, it  will  often  be  found  more  convenient 
Petit's  tourniquet,  to  lay  a  firm  roll  of  bandage,  about  an  inch 
in  diameter,  along  the  course  of  the  artery, 
and  then  to  pass  the  strap  over  it.  In  this  way  the  instru- 
ment may  be  shifted  without  interfering  with  the  position  of  the 
roll  of  bandage  which  serves  as  a  pad.  The  screw  should  not  be 
turned  until  the  moment  when  the  incisions  are  about  to  be 
made;  for,  if  it  is,  the  parts  will  become  congested,  and  there  will 


AMPUTATIONS. 


397 


be  an  unnecessary  loss  of  blood.  For  the  same  reason,  as  soon  as 
the  principal  vessels  have  been  tied,  the  tourniquet  should  be 
relaxed,  so  that  no  impediment  may  be  offered  to  the  return  of 
the  venous  blood. 

When  the  amputation  is  high  up  in  the  thigh  it  is  impossible 
to  use  Petit's  tourniquet;  and  then  the  surgeon  must  either  apply 
a  compressor  over  the  abdominal  aorta,  or  he  must  direct  an 
assistant  to  make  digital  pressure  upon  the  common  femoral 
artery  as  it  passes  over  the  brim  of  the  pelvis. 

In  the  upper  part  of  the  thigh,  the  operation  by  means  of 
antero-posterior  flaps,  made  by  transfixion,  is  the  most  suitable  ; 
or  the  anterior  flap  may  be  made  by  transfixion,  and  the  posterior 
one  by  a  transverse  semicircular  sweep  of  the  knife.  In  the 
middle  and  lower  parts,  the  surgeon  has  his  choice  of  several 
methods.  He  may  perform  a  circular  operation;  or  a  flap 
operation  with  antero-posterior  flaps  made  by  transfixion,  or 
with  lateral  flaps  made  in  the  same  way ;  or  he  may  prefer  the 
rectangular  flaps  (Teale's  operation) ;  or  he  may  make  skin  flaps, 
by  cutting  from  without  inwards,  and  divide  the  muscles  circularly. 
In  making  lateral  flaps,  the  inner  flaps,  which  contain  the  large 
vessels,  should  always  be  made  last. 

Dressings  may  be  applied  to  the  stump  in  the  manner  that  I 
have  explained  in  speaking  of  amputation  of  the  forearm.  lu 
bandaging  a  stump  in  the  thigh,  the  surgeon  begins  by  taking  one 
or    two     circular    turns 


round  the  part,  with  the 
view  of  fixing  the  end 
of  the  roller — holding  it 
(let  us  suppose)  in  his 
right  hand.  Then  he 
secures  the  last  fold  with 
the  thumb  of  his  left 
hand,  while  with  the 
other  he  carries  the 
bandage  at  right  angles 
over  the  end  of  the 
stump  to  a  point  directly 
opposite  to  that  from 
which  he  started.  Here 
he  secures  the  bandage 
with  the    fingers  of  his 


Fig.  184. 


Bandage  for  a  stump. 


left  hand,  while  he  takes  a  circular  turn  round  the  limb  to 
fix  the  fold  which  passes  over  the  stump.  Or  he  may  take  two 
or  three  folds  consecutively,  and  then  fix  them  all  by  a  single 
turn  round  the  limb.     These  steps  he  repeats  as  often  as  they 


398  OPERATIONS. 

are  necessary,  until  the  whole  of  the  stump  is  covered  (Fig. 
184). 

Amputation  at  the  Icnee-joint  is  an  operation  which  has  occa- 
sionally been  performed  ever  since  the  fifteenth  century  ;  but  it  is 
only  of  late  that  it  has  taken  an  established  place  in  surgery,  in 
consequence  of  the  recommendation  of  Velpeau,  Syme,  and  more 
particularly  of  Mr.  Gr.  D.  Pollock.  His  Paper  upon  the  subject, 
in  the  53rd  volume  of  the  "  Medico-Chirurgical  Transactions," 
gives  a  full  account  of  the  operation,  and  of  the  way  in  which  it 
should  be  performed  under  different  circumstances.  Speaking 
generally,  a  large  and  broad  flap  should  be  taken  from  the  front  of 
the  leg,  and  a  shorter  one  from  the  back.  These  flaps  should  consist 
of  nothing  but  the  integument.  The  patella  and  the  condyles  of 
the  femur  need  not  be  touched,  unless  they  are  ulcerated ;  in 
which  case  the  patella  should  be  dissected  out,  and  a  sufficient 
slice  taken  off  the  condyles  of  the  femur  to  remove  the  whole  of 
the  disease.  Mr.  Pollock  speaks  favourably  of  the  operation,  both 
as  regards  the  stump  which  is  left,  and  as  to  the  mortality  when 
compared  with  amputation  through  the  thigh. 

Amputation  of  the  leg  may  be  performed  either  immediately 
below  the  knee,  in  the  middle  of  the  leg,  or  in  the  lower 
third. 

A  semicircular  flap  is  taken  ftum  the  front  of  the  leg,  by 
cutting  from  without  inwards ;  the  limb  is  then  transfixed — 
care  being  taken  not  to  pass  the  knife  between  the  bones — and 
a  long  thick  flap  is  made  from  the  posterior  aspect.  Or,  the 
surgeon  may  adopt  Mr.  Teale's  plan,  and  mark  out  a  couple  of 
rectangular  flaps,  the  longer  one  being  taken  from  the  extensor, 
and  the  shorter  from  the  flexor  side.  Or,  he  may  prefer  to  use 
the  circular  method. 

In  dressing  a  stump  in  the  leg  the  many-tailed  bandage  is 
often  useful,  and  we  may  take  this  opportunity  of  describing  it, 
though  it  is  suitable  to  other  situations  as  well.  It  is  made  in 
the  following  maimer : — The  surgeon  cuts  a  number  of  strips  of 
"leg-bandage,"  sufficiently  long  to  go 
once  and  a  half  round  the  part.  These 
he  lays  in  regular  order,  from  above 
downwards,  one  overlapping  the  other  to 
about  a  third  of  its  width.  It  will  be 
seen  immediately  that  it  is  necessary  to 
follow  this  plan  in  order  that  the  bandage 
may  lie  flat,  when  it  is  applied  (according 
to  the  general  rule),  from  below  upwards. 
Many-tailed  bandage.  A  sufficient  number  of  strips  ought  to 
be  taken  to  cover  the  whole  extent  of 
surface  to  which  the  bandnge  has  to  be  applied,  and  the  length  of 


AMPUTATIONS. 


399 


Fig.  186. 


the  pieces  must  vary  according  to  the  size  of  the  part  which  they 
have  to  surround.  Sometimes  the  strips  are  stitched  to  a  longi- 
tudinal band,  which  serves  to  keep  them  in  their  places 
(Fig.  185).  When  the  bandage  has  been  prepared  the  limb  is 
laid  upon  it,  or  the  strips,  arranged 
upon  a  piece  of  pasteboard,  arc 
shpped  under  the  limb;  and  then 
each  separate  piece  is  made  to  en- 
circle the  part,  the  ends  being 
brought  up  one  on  each  side  and 
crossed  in  front.  The  lowest  piece 
should  be  folded  first,  and  then  the 
pieces  should  be  taken  in  regular 
order  from  below  upwards.  This  is 
a  very  convenient  bandage  where  the 
surgeon  thinks  it  a  matter  of  import- 
ance to  keep  the  aiFected  part  as 
quiet  as  possible.  It  serves  to  retain 
dressings,  and  at  the  same  time  it 
gives  a  shght  amount  of  support.  Mode  of  applying  the  many- 
Moreover,   as  it  is  capable  of    being  tailed  bandage. 

unfolded   piece   by  piece,  the  stump 

may  be  readily  exposed  without  interfering  to  any  extent  with  the 
comfort  of  the  patient.  The  annexed  illustration  represents  a 
stump  in  the  lower  third  of  the  leg,  partially 

covered   by  a    many -tailed    bandage    (Fig. 

186). 

Amputation    at    the  ankle-joint    {Syme's 

operation)     is     performed    by    making    an 

incision   from    one    malleolus   to  the    other, 

across  the  under-surface  of  the  foot,  imme- 
diately   in   front  of  the    heel.      The  points 

of  this  incision  are  then  united  by  a  second, 

passing  across  the  instep.       Or  the  super- 
ficial incision   may  be  made    at    one    sweep, 

the  knife  being  carried  across  the  instep  and 

round  the  front   of   the   heel,  to  the  point 

where  it  began.     The  joint  should  then  be 

opened  from  the  front,  the  tendons  and  liga- 
ments divided,   and   the    dissection    carried 

round  the  os  calcis — great  care  being  taken 

to  keep   close  to  the  bone,  particularly  on 

the  inner  side,  where  it  is  in  contact  with 

the  posterior  tibial  vessels.      The    malleoli 

should    then    be    cut    off,    and    the    flaps 

brought  together.     The  advantages  of  this  operation  are,  that 


Fig.  187. 


Stump  after  Piro- 
goff's  operation. 


400 


OPERATIONS. 


the  foot  is  removed,  while  the  limb  is  but  little  shortened,  and 
that  an  excellent  covering  is  made  for  the  end  of  the  stump  from 
the  thick  and  tough  skin  of  the  heel. 

M.  Pirogoff  has  introduced  a  modification  of  this  operation, 
which  consists  in  leaving  the  posterior  half  of  the  os  calcis,  and 
turning  it  up,  so  as  to  bring  the  sawn  surface  into  apposition 
with  the  ends  of  the  tibia  and  fibula.  In  performing  the  opera- 
tion an  incision  should  first  be  made  from  one  malleolus  to  the 
other,  passing  under  the  sole.  This  incision  should  not  be  ver- 
tical, but  tending  slightly  forwards  in  an  oblique  direction.  The 
flap  thus  indicated  should  be  carefully  dissected  back  for  a  short 
distance.  The  ankle-joint  is  next  opened  by  an  incision  across 
the  instep,  and  the  astralagus  is  disarticulated.  The  saw  is  then 
applied  to  the  upper  surface  of  the  os  calcis,  immediately 
behind  the  articulation  with  the  astragalus,  and  the  bone  is  cut 
through  from  above  downwards,  and  in  an  oblique  direction  from 
behind  forwards.  The  malleoli,  together 
with  the  articulating  surfaces  of  tlie 
tibia  and  fibula,  are  sawn  off,  and  the 
operation  is  completed  by  bringing  the  two 
osseous  surfaces  into  contact,  and  uniting 
the  line  of  incision  by  interrupted  sutures. 
In  order  to  facilitate  union  between  the 
bones,  it  is  well  to  divide  the  tendo 
Achillis  subcutaneously.  By  Pirogoff's 
operation  the  length  of  the  limb  is  pre- 
served, while  the  resulting  stump  has  a 
covering  of  the  naturally  thick  skin  which 
protects  the  heel.  Fig.  187,  which  was 
taken  from  a  case  of  Mr.  Canton's, 
shows  what  a  satisfactory  stump  may  be 
obtained  by  this  operation.  It  should 
not  be  undertaken  where  there  is  exten- 
sive disease  of  the  tarsus,  even  though 
the  OS  calcis  may  be  sound;  for  in  such 
instances  the  disease  is  very  apt  to  mani- 
fest itself  in  the  stump.  But  in  cases  of 
injury  it  is  an  excellent  operation. 

In  cases  in  which  the  anterior  bones 
of  the  tarsus  are  diseased  or  injured, 
while  the  astragalus  and  os  calcis  remain 
healthy,  Mr.  Hancock  has  devised,  and 
practised  with  success,  an  operation 
whereby  the  calcaneum  is  sasvn  through 
obliquely,    the    front  of  the    foot   taken 


Diagram  of  the  bones 
of  the  foot. 


AMPUTATIONS. 


401 


away,  the  head  of  the  astragalus  and  its  inferior  articulating  sur- 
faces removed,  and  the  sawn  surface  of  the  heel-bone  brought 
into  apposition  with  the  under  surface  of  the  astragalus.  By 
this  operation  the  ankle-joint  is  left  intact;  tlie  stump  is  formed 
by  the  tuberosity  of  the  os  calcis,  which  is  retained  in  the 
integument,  and  covered  by  the  thick  skin  which  is  natural  to  it 
("  Surgery  of  the  Human  Foot,"  p.  209). 

Amputation  througJi  the  tarsus  {Chofarfs  operation)  consists 
in  disarticulation  between  the  os  calcis  and  astragalus  on  the  one 
hand,  and  the  scaphoid  and  cuboid  on  the  other  (Fig.  188,  a). 
The  sole-flap  should  first  be  marked  out  by  an  incision  from  the 
tubercle  of  the  scaphoid,  along  the  side  of  the  foot,  to  the  ball 
of  the  great  toe ;  the  knife  should  next  be  carried  across  the 
sole,  a  little  behind  the  roots  of  the  toes ;  and  then  turned 
along  the  outer  side  of  the  foot,  to  a  point  a  little  behind 
the  prominent  base  of  the  fifth  metatarsal  bone.  An  incision  is 
next  to  be  made  across  the  instep,  so  as  to  unite  the  ends  of  the 
former  incision.  The  articulations  are  then  opened,  and  the 
dissection  carried  ou  close  to  the  under  surface  of  the  bones,  so 
as  to  leave  the  whole  of  the  soft  tissues  of  the  sole  in  the 
plantar  flap. 

This  is  a  good  operation,  and  the  result  is  generally  satis- 
factory ;  and  when  a  methodized  operation  through  the  tarsus  is 
required,  the  surgeon  can  adopt  no  better. 
But,  as  I  have  already  said,  there  is  at  the 
present  day  a  strong  tendency  among  sur- 
geons to  remove  only  the  diseased  or  mu- 
tilated parts,  and  to  retain  all  that  can 
with  any  propriety  be  left.  This  practice 
is  founded  partly  upon  the  confident  expec- 
tation that  nature  will  bind  together  and 
utilize  all  that  remains,  but  still  more 
upon  the  ascertained  fact  that  the  morta- 
lity increases  in  direct  proportion  to  the 
amount  that  is  taken  away.  Acting  upon 
this  principle  in  the  case  of  a  man,  aged 
sixty-one,  who  was  injured  in  a  railway 
accident,  I  disarticulated  the  three  cunei- 
form bones  from  the  scaphoid,  and  sawed 
ofl"  the  projecting  extremity  of  the  cuboid. 
The  patient  made  an  excellent  recovery, 
and  the  appearance  of  the  stump,  some  two 
years  after  the  operation,  is  represented 
in  Fig.  189.  The  particulars  of  the  case  are  related  in  the 
Lancet  of  Nov.  20,  1869. 

B  D 


Stump  after  amputa- 
tion through  the 
tarsus. 


402 


OPERATIONS. 


Amputation  at  the  line  of  the  metatarsal  hones  [Hef/'s 
operation)  consists  in  making  a  large  plantar  flap  and  a  small 
dorsal  one,  and  then  disarticulating  the  metatarsal  from  the 
tarsal  bones  (Fig.  188,  b).  In  doing  this,  the  surgeon  should 
bear  in  mind,  that  the  base  of  the  second  metatarsal  bone  is 
deeply  sunk  between  the  internal  and  external  cuneiform  bones. 
As  disarticulation  is  difiicult,  and  offers  no  special  advantages, 
the  bones  are  sometimes  sawn  through  just  in  front  of  the  joints. 
This  I  have  seen  done  by  Sir  Wm.  Fergusson,  with  excellent 
results,  in  the  case  of  a  sailor  who  had  lost  his  toes  from  frost- 
bite consequent  upou  long  immersion  in  the  sea. 

Fig.  190,  which  is  copied  from  the  original  illustration  in  Hey's 

Surgical   Observations,  gives  a 


Fig.  190. 


i 

- 

--^ 

^       .f^' 

"^^^^^ 

\         J^^' 

"^^ 

m 

'      IW»^' 

'^^Sr-' 

1    Im^-- 

'IIP'--" 

VIp 

S 

1 )% 

V  '     '      -■''iV'-^'- 

\r^ 

1 

'  ~ 

.1^ 

SM 


Hay's  operation. 


good  idea  of  the  stump  which 
is  left  after  this  operation. 

The  metatarsal  bone  of  the 
great  toe,  which  is  often  affected 
by  strumous  disease,  may  be  re- 
moved by  an  incision  carried 
along  its  dorsal  surface,  from 
its  base  to  its  head,  and  then 
turned  down,  at  right  angles, 
to  the  ball  of  the  toe.  The 
surgeon  should  be  careful  not 
to  interfere  with  the  sole ;  and, 
if  possible,  the  base  of  the  bone 
should  be  left,  because  it  gives 
insertion  to  the  peroneus  longus. 

The  toes,  or  any  of  their 
phalanges,  may  be  amputated 
^much  in  the  same  way  as  the 
corresponding  parts  of  the  hand. 

The  toes  should  be  removed 


by  the  oval  method,  the  surgeon  commencing  his  incision  on 
the  dorsal  surface,  well  above  the  web,  and  carrying  it  obliquely 
forward,  so  that  on  the  plantar  surface  it  may  not  interfere  with 
the  tread  of  the  foot. 


FORMULiE   AND   RECEIPTS. 


The  Doses  are  apportioned  for  Adults,  and  the  mixtures  and 
pills  are  to  he  taken  three  times  a  day,  except  ivhere  otherwise 
stated. 

1.  Fotus  Bclladonnee. 

BL  Extract!  belladonnae gr.  60 

To  be  dissolved  in  one  pint  of  boiling  water,  and  used  as  a 
fomentation. 

2.  Fottis  Papaveris. 

R   Capsul.  papaveris  contus 5j 

Aquae  destillatse Oj 

Mix,  and  boil  for  a  quarter  of  an  hour ;  then  strain  through 
muslin. 

3.  Gargarisma  Aluminis. 

R   Aluminis  exsiccati gr.  80 

Tinct.  myrrbae      .     .     .     .     .     .     .     .    oj 

Aquae ad  §viij 

Misce. 

4.  Garg.  Alum,  et  Capsici. 

B-   Aluminis  exsiccati gr.  60 

Tinct.  capsici 5s8 

Syrupi  mori §j 

Aqua3  rosse ad  §  viij 

Misce. 

5.  Guttee  Argenti  Nitratis. 

B-    Argenti  niti-atis    .     .     .     .     .     .    gr.  1 — 2 

Aqnre  destillatse •  .     .     .    5j 

Misce. 

To  be  dropped  into  the  eye  with  a  glass  rod  or  a  camel's-hair 
brush. 

D  D  2 


404  FORMULA  AND  EECEIPTS. 


6.  Gnttae  Atropiae  Sulphatis. 

B    Atropiffi  sulphatis gr.  1 — 4 

Aqufe  destillatje 5j 

Misce. 


7.  Haustus  Hyoscyami, 

R   Tinct.  hyoscyami ni  25 — 60 

[vel  Tinct.  lupuli       .     .     .     .      m  30—60] 

Liq.  ammonise  acet 3.1 

Syr.  Tolutani 5ij 

Mist.  caraphor?e ad  §iss 

Misce. 

A  soothing  or  sleeping  draught,  without  opium.     To  be  taken  at 
bedtime,  or  night  and  morning. 


8,  Injectio  Bismnthi. 

R    Bismuthi  subnit ^i\ 

Glycerin!     .  §j 

Aqufoi ad  5xJ 

Misce. 

Useful  in  gonorrhoea,  urethritis,  and  vaginitis. 


9.  Injectio  Boracis  at  Glycerini. 

R   Glycerini 5i.i 

Boracis §j 

Aquse §i} 

Misce. 

Put  3j  or  3ij  into  §iv.  of  warm  water,  and  inject  into  the  bladder 
in  cases  of  cystitis,     (Sir  H.  Thompson.) 


10.  Injectio  Morphige. 

R   Morphise  acetatis gr.  80 

Aquse  destillatte ,     .      .    5j 

liub  the  acetate  gradually  with  the  water,  and  a-ld  a  few  drops 
of  acetic  acid,  if  necessary  for  perfect  solution.  Six  drops  con- 
tain one  grain  of  acetate  of  morphia.  For  subcutaneous  injection. 
(^Middlesex.) 


FORMULAE   AND  RECEIPTS.  406 


11.  Linctus  Morphise. 

R'  Liq.  morpliiaj ni  4 

Aquai  laurocerasi tn,  2 

Syr.  Tnlutani in  30 

Glycerini ad  3j 

Misce. 

Dose — a  teaspoonful  occasionally. 

12.  Lotio  Acidi  Carbolici. 

R   Acidi  carbolici  crjstalli     ,     .     .      .     gr.  1 

Aqn?e  destillatas iH  40 

Misce.  {St.  George's,  Charing  Cross.) 

13.  Lotio  Acidi  Nitrici. 

R   Acidi  nitrici  fort .......       m  4 

Tinct.  opii m,  6 

Aquae  destillatse gj 

Misce.  (Ki7ig's  College.) 

14.  Lotio  Acidi  Sulphurosi. 

R   Acidi  sulpliurosi 3.]* 

Aquae  destillatae ad  §j 

Misce.  {Middlesex.) 

15.  Lotio  Acidi  Tannici. 

R    Acidi  tannici gr.  4 

Sp.  vini  rectificati IH,  30 

Aquae  rosfe 5ij 

Aquae  destlllatae ad  §j 

Misce. 


16.  Lotio  Aluminis  Mitior. 

R    Aluminis  exsiccati  ......     gr.  3 

Aquse  destillatae §j 

Misce. 


17.  Lotio  Aluminis  Fortior. 

R   Aluminis  exsiccati gi'.  6 

Aquae  destillatae 5j 

Misce. 


406  FORMULA  AND  EECEIPTS. 


18.  Lotio  Ammon.     Hydrochlor. 

R   Ainmoni?e  hydrochloratis  .     .     .     .  gr.  24 

Acidi  acetici  diluti th,  48 

Sp.  -^ani  rectificati tT],  30 

Mist,  camplioras ad  §j 

Misce. 


19.  Lotio  Arnicse. 

R.    Tinct.  arnicse tn,  20 

Liq.  ammon.  acet itj,  30 

Sp.  rosmarini ni  15 

Aquse  destillataB ad  5.1 

Misce. 


20.  Lotio  Boracis  et  Glycerini. 

R   Boracis gr-  6 

Glycerini        5,1* 

Aquae  sambuci .     .  3ll 

Aquse  destillatse ad  §j 

Misce. 


21.  Lotio  Evaporans. 

(1)  R   Sp.  ^etheris  nitrosi Til  10 

Acidi  acetici  aromatici ITI    2 

Aquae  destillatse 5j 

Misce. 

(2)  R    Ammonise  hydrochloratis  .     .     .     .  gr.  12 

Sp.  vini  rectificati ni  36 

Aquae ad  5j 

Misce.  {Charing  Cross.) 

(3)  R   Liq.  amraonife  acet tti  108 

Sp.  vini  rectificati in  108 

Aquae ad  §j 

Misce.  {St.  Thomas's.) 


22.  Lotio  Myrrhse. 

R   Tinct.  myiThse m  72 

Aquae ad  5J 

Misce.  {King's  College.) 


FORMULA  AND  EECEIPTS.  407 


23.  lotio  Plumbi. 

R    Plumbi  acetatis gr,  2 

Acidi  acetici  dil tn,  2 

Aquae  destillatse 5J 

Misce. 


24.  Lotio  Plumbi  c.  Opio. 

R   Tinct.  opii 5.1 

Sp.  rosniarini 5.1 

Liq.  plumbi  subacetatis  dil.    ,     .     .ad  §j 

Useful  for  erysipelas,  irritable  ulcers,  chilblains,  &c. 

25.  Lotio  Zinci  Sulphatis  (L.  rubra). 

R   Zinci  sulphatis gr.  I 

Sp.  rosmarini tti  15 

Tinct.  lavandulae  co tn,  15 

Aquae  destillatse o.j 

Misce.  {Middlesex.) 

26.  Lotio  Zinci  et  Aluminis. 

I^   Zinci  sulphatis gr.  2 

Aluminis  exsiccati gr.  2 

Aquae 5j 

Useful  in  some  acute  forms  of  ophthalmia. 

27.  Lotio  Zinci  Chloridi  (Mitior). 

R   Zinci  chloridi gr.  1 — 5 

Aqiife 5j 

Misce. 

28.  Lotio  Zinci  Chloridi  (Fortior). 

B-   Zinci  chloridi gr.   20 — 40 

Aquae 5j 

Misce.  (Mk.  Campbell  de  Morgan.) 

29.  Mistura  Acidi  G-allici. 

R   Acidi  gallici    .......     gr.  10 — 20 

Acidi  sulph.  dil tn  15 — 20 

Tine,  cinnamomi 5iss 

Aquse  distillatse ad  §iss 

Misce. 


408  f'ORMUL^  AND  RECEIPTS. 


30.   Mistura  Acidi  Nitrici  Dil. 

(1)  R    Acidi  nitrici  dil HI  15 

Tiuct.  lupuli rn,  45 

Inf.  cascarillae 5j 

Misce.  (University  College.) 

(2)  R    Acidi  nitrici  dil nt  10 

Tinct.  card,  co 3j 

Infusi  gentianse  co §iss 

Misce.  {St.  TJiomas^s.) 


31.    Mist.  Acidi  Nitro-Hydroclilor.  Dil. 

(1)  R    Acidi  nitro-hydrochlor.  dil.      .     .     .     iti  15 

Infusi  chiratse 5.1* 

Misce.  (King's  College.) 

(2)  R   Acidi  nitro-hydroclilor.  dil.     ...      iri  5 

Tinct.  chiratse tri  20 

Sjr.  aurantii 3j 

Infusi  aurantii ad  5j 

Misce. 

(3)  Bt   Acidi  nitro-hydrochlor.  dil.      .     .     Tii  5—10 

Sp.  chloroforrai m  10 — 15 

Ext.  cinchona  flavse  liq.      .     .       ni  10 — 15 

Aqu£e ad  5 

Misce. 


32.   Mistura  Acidi  Salph.  Dil. 

R   Acidi  Sulphurici  dil tn,  10 

Decocti  cinchonse 5j 

Misce.  {St.  Thomas's.) 


33.  Mistura  Salina. 

R   Sp,  setheris  nitrosi 5y 

Liq.  ammon.  acet oiij 

Aquae  campborse ad  5iss 

Misce. 


34.  Mist.  AmmoniGe  Garb. 

(I)  R   Ammonijecarb gr, 

Infusi  cinchonse 5,1* 

Misce.  {King's  College.) 


FORMULA  AND  EECEIPTS.  409 

(2)  R   Ammonige  carb.  .     ...     .     .    gr.  3 — 5 

Tinct.  card.  CO 5.j 

Sp.  chloroformi Til  30 

Tinct.  cliiratiB rn,  5 

Syr.  aurantii 5iss 

Aquae ad  giss 

Misce. 

35.  Mist.  Ammonise  Effervescens. 

(1)  R   Ammonisecarb gr.  10 

Sp.  ammon.  aromat tn.  10 

S}T.  zingiberis 5,j 

Aquffi ad  5j 

To  be  taken  in  effervescence  with 

Acidi  tartarici gr-  8 

Aquae §ss 

(2)  B.   Ammonite  carb gr.  6 

Sp.  chloroformi til  20 

Tinct.  calumbse m  10 — 20 

Syr.  zingiberis tn,  30 

Aquae ad  §j 

To  be  taken  in  effervescence  with  a  table-spoonful  of  fresh  lemon 
juice. 

36.  Mist.  AmmoniEe  Hydrochloratis. 

R   Animoniae  hydrochlor gr.  5 

Acidi  hydrochlor.  dil ni  8 

Syr.  rhoeados ni  30 

Aquae  destillatse ad  5j 

Misce. 

37.   Mist.  Ammoniee  c.  Scilla. 

(1)  R   Ammoniae  carb gr.  3 — 5 

Sp.  chloroformi lU  20 — 30 

Tinct.  scillae tn,  10 — 15 

Infusi  senegas ad  5j 

Misce. 

(2)  R   Sp.  ammoniie  aromat lU  20 

Sp.  chloroformi TH,  20 

Oxymel.  scillae ill  10 

Aquae ad  5j 

Misce. 


410  FOEMUL^  AND   RECEIPTS. 


38.  Mist.  Antimonii  Tartarati, 

(1)  R    Antimonii  tartarati gi*.  ^ 

Liq.  ammonise  acet 3i.j 

Aquae  camphorae a-d  §j 

Misce.  (St.  Mary's.) 

(2)  R.    Vini  antimonialis iri  20 

Liq.  ammoniae  acet 3iss 

Tinct.  hyoscyami  .     .     .     .     .     .     .  Tri  15 

Aquae  destillatse    . ad  5j 

Misce. 

89.  Mist.  Antimonii  Tart.  c.  Opio. 

R  Antimonii  tartarati gr.  4 

Tinct.  opii iri  40 

Aquae o^'^j 

Misce. 

One  table- spoonful  to  be  taken  every  hour.        (Dr.  Graves.) 

40.  Mist.  Cathartica. 

R.   Tinct.  zingiber! 8  fort ni  5 

Magnesiae  sulph gc.  120 

Syr.  sennae 3.] 

Mannae gr.  30 

Infusi  sennae ad  giss 

Misce. 

A  draught  to  be  taken  in  the  morning. 

41.  Mist.  Chloral.  Hydrat. 

R   Chloral,  hydrat gr.  10—20 

Tinct.  aurantii 5j 

Aquae ad  5iss 

Misce. 

A  draught  to  be  taken  at  bedtime. 

42.  Mist.  Cinchonae  Co. 

R   Tinct,  cinchonae  co 3.1 — 3i,i 

Sp.  chloroformi ni  20 — 30 

Aquae .  ad  5j 

Misce. 


FOEMUL.^  AND  EECEIPTS.  411 


43.  Mist.  Gopaibae. 

R    Copaibfe "1 .20 

Mucilaginis  acacise 3ijss 

Aquse  cinnamomi ad  oj 

Misce. 


44.  Mist.  Cubebae. 

R   Pulv.  cubebae Sss 

Mucilag.  acaciae 5ij 

Tinct.  hyoscjami 3ss 

Sp.  xth.  r.it Sss 

Syr.  simplicis 3ss 

Aqu?e  cinnam ad  5j 

Misce. 


45.  Mist.  Ferri  lodidi. 

R    Syr.  ferri  iodidi 5.1 

Syr.  rboeados ttl  15 

Aquae ad  5j 

Misce. 


46.  Mist.  Ferri  et  Mag.  Sulph. 

R   Ferri  sulpbatis gr.  2 

Magnesiae  suipliatis gr.  20 

Acidisulpk  dil ni  10 

Aquae  pimentae oj 

Misce. 


47.  Mist.  Ferri  Perchloridi. 

R   Tinct.  ferri  perchloridi ni  1 0 

Sp.  chloroformi tti  20 

Inf.  quassiae ad  oj 

Misce. 


48.  Mist.  Ferri  c.  Zingibere. 

R   Tinct.  ferri  perchlor ni  10 

Tinct.  zingiberis tn,  30 

Syr.  simplicis 5j 

Aquae ad  5j 

Misce. 


412  FOEMUL^  AND  RECEIPTS. 


49.  Mist.  Hydrarg-yri  lodidi. 

R   Liq.  liydrarg.  percliloridi 5j 

Potassii  iodidi gr.  5 

Infusi  quassias ad  5j 

Misce, 


50.  Mist.  Hydrarg.  Percliloridi. 

(1)  R   Liq.  hydrarg.  perclilor 3j 

Tinct.  gentianse  co ni  20 — 30 

Syr.  aurantii ni  30 

Aquas  destillatse ad  5j 

Misce. 


(2)  R.   Hydrarg.  percliloridi gr.  ^^ 

Sp.  vini  rectificati lU  10 

Aqu£e 5j 

Misce.  {^London.) 


51.  Mist.  Lobelise  .Sltherese. 

R    Sp.  Ammon.  co m  30 — 60 

Tinct.  lobeliee  £etli in  20—30 

Aquse ad  5j 

Misce. 


52.  Mist.  Nucis  Vomicse. 

R   Tinct.  nucis  vom. tn  10— 20 

Acid,  nitro-hydrochlor.  dil.     .     .  lU  10 — 20 

Tinct.  aurantii ni  20 — 30 

Syr.  aurantii 5j 

Aquae ad  5j 

Misce. 


53.  Mist.  Morphiae  Acetatis. 

R    Liq.  Morphiae  acet nt  10 — 30 

Liq.  ammon.  acet 5ij 

Mist,  camph ad  §j 

Misce. 


FOEMULiE  AND  EECEIPTS.  413 


54.  Mist.  Olei  Santal.  Flav. 

R    Olei  santal,  flav tn  30 

Mucilag.  acacise 3j 

Syr.  symplicis 5j 

Tinct.  aurantr ni  30 

Aquae aJ  5j 

Misce. 


55.  Mist.  Fotassse  Acetatis. 

(1)  R    Sp.  setheris  nitrosi ni  30 

Potassae  acetatis gr.  20 

Decocti  scoparii 5j 

Misce.  {Charing  Cross.) 

(2)  R   Potassse  acetatis gr.  10 

Tinci.  scillse .  ni  15 

Sp.  eetlieris  nitrosi ni  20 

'Jinct.  hyoscyami rn,  10 

Aquae ad  5j 

Misce. 

A  useful  diuretic  mixture. 


56.  Mist.  Fotassae  Bicarbouatis. 

(1)  R   Pot assae  bicarb gr.  10 — 20 

Syr.  zingiberis 5j 

Aquae ad  5j 

Misce. 

Ten  or  fifteen  drops  of  tbe  vinum  colchici,  and  tbe  same  quan- 
tity of  the  tincture  of  hyoscyamus,  may  be  added  to  each  dose  if 
the  patient  is  of  a  gouty  habit. 

(2)  R   Potassae  bicarb gr.  30 

Syr.  simplicis in  30 

Aquae giss 

To  be  taken  in  effervescence  with  a  dessert-spoonful  of  fresh 
lemon  juice. 

57.  Mist.  Potassii  Bromidi. 

R    Potassii  bromidi g''  lo 

Infusi  quassiae 5j 

Misce.  {Charing  Cross.) 


414  FORMULA  AND  EECEIPTS. 


58.  Mist.  Fotassii  Bromidi  Co. 

R    Potassii  bromidi gr.  10 

Sp.  cliloroformi ni  18 

Infusi  quassias 5j 

Misce.  (University  College.) 

59.  Mist.  Fotassse  Chloratis. 

R.   Potasses  cUoratis gr.  6 

Sjr.  tolutani 5j 

Aquee  destillatae .     .     .     .     .     .     .    ad  §j 

Misce. 


60.  Mist.  Potassii  lodidi. 

(1)  R    Potassii  iodidi gr.  3 — 5 

Tinct.  aurantii tn,  20 

Sp.  chloroformi Tti  10 

Infusi  gentianas  co ad  §j 

Misce. 

(2)  B,  Potassii  iodidi gr.  5 

Ext.  sars06  liq 5j 

Misce. 


To  be  taken  in  two  table-spoonfuls  of  wate 


(3)  R    Potassii  iodidi gr.  5 — 10 

Sp.  ammonise  aromat TH,  30 

Tinct.  aurantii ni  40 

Syr.  aurantii 5j 

Aquae ad  gj 

Misce. 

(4)  B.   Potassii  iodidi gr.  5 — 10 

Tinct.  card,  co IH.  20 

Sp.  chloroformi tn,  10 

Syr.  zingiberis 5j 

Aquae ad  5j 

Misce. 


61.  Mist.  Potassii  lodidi  c.  Colchico. 

B-   Potassii  iodidi gr.  2 — 5 

Potasste  bicarb gr.  10 

Tinct.  colchici iti  10 — 20 

Aquae  destillatse ad  5j 

Misce. 


FORMULAE  AND   RECEIPTS.  415 


62.  Mist.  Potassii  c.  Ferro. 

(1)  Bt    Potassii  iodidi g^-  24 

Ferri  et  iimmoniae  citratis .     .     .     .    gr.  5 

Aquae  pimentse 5j 

Misce.  {London.) 

(2)  R   Potassii  iodidi gi'.  10 

Ferri  tartarati gr,  20 

Aquse 5j 

Misce.  {King's  College.) 

(3)  R   Potassii  iodidi gr-  5 

Sp.  ammon.  aromat tri  20 

Ferri  tartarati gr.  10 

Aqufe  destillatse §j 

Misce. 

(4)  R.   Potassii  iodidi gr.  3 — 5 

Ferri  et  ammonise  cit gr.  5 — 10 

Sp.  cbloroformi iri  20 — 30 

Aquae ad  5j 

Misce. 


63.  Mist.  Fotassse  Liqaoris. 

(1)  R   Liq.  Potassae ra  10 — 20 

Liq.  opii  sed rn,  5 — 10 

Mist,  amygdalae 5j 

Misce. 

(2)  R   Liq.  potassae ttl  10—20 

Tinct.  hyoscyami iH,  10 — 15 

Aquae  camphorse 5j 

Misce. 


64.  Mist.  Potassae  Nitratis. 

R    Potassae  nitratis gr.  15 

Sp.  aetlieris  nitrosi tri  15 

Syr.  limonis tn,  40 

Aquae  mentliae §j 

Misce.  "  {Guy's.) 

65.  Mist.  Quiuiee. 

(1)  R    Tinct.  quiniae 5j 

Syr.  simplicis ni,  30 

Aquaj ad  5j 


416  FOEMUL^  AND  EECEIPTS. 

(2)  R   Tinct.  quiniae ta  20 

Acidi  sulph.  dil vey  6 

Syr,  simplicis ni  30 

Aquae  destillatge ad  5j 

(3)  R   Quinise  sulphatis gr.  1 — 2 

Acidi  hydrobromici      ....  HI  10 — 20 

Syr.  aurantii  floris 5j 

Aquae ad  3j 

Misce. 


66.  Mist.  Quinise  c.  Ferro. 

(1)  R.   QuinijB  sulphatis gr.  1 

Ferri  sulphatis gr.  1 

Acidi  sulph.  dil rf[  B 

Syr.  simplicis 3.1 

Aquae ad  5j 

Misce. 

(2)  Bt   Quinise  sulphatis gr.  1 

Tinct.  ferri  perchlor TTl  10 

Acidi  nitrici  dil Tti  5 

Aquae ad  §j 

Misce. 


67.  Mist.  Sodae  Bicarbonatis. 

R    Sodae  bicarb gr.  10—20 

Acidi  hydrocyanici  dil .      ...     tti  3 — 5 

Mist,  camphorae 5j 

Misce. 


68.  Mist.  Sodee  Bicarb.  Effervesceus. 

(1)  R.    Sodae  bicarb gr.  10 

Potassae  bicarb gr.  5 

Ammonise  carb gr-  6 

Tinct.  calumbse tti  20 

Syr.  aui'antii tti  30 

Aquae §iss 

To  be  taken  in  effervescence  with  a  dessert-spoonful  of  fresh 
lemon  juice. 


FORMULA  AND  RECEIPTS.  417 

(2)  R   8ocl£e  bicarb gr.  20 

Syr.  limonis ^  ^9. 

Aquae ad  oij 

To  be  taken  in  effervescence  with  eighteen  grains  of  citric  acid. 
Fifteen  or  twenty  drops  of  sp.  cliloroformi  may  be  added  to  each 
dose  if  a  stimulant  is  needed. 


69.  Mist.  Sodae  SulpMtis. 

R   Sodse  sulphitis »''•  1?. 

Liq.  amnion,  acet §i,j 

Mist,  camph ad  oj 

Mi  see. 


70.  Mist.  Strychnise  c.  Ferro. 

(!)  R    Liq.  stiTchnias IH  5 

Acidi  nitro-hydrochlor.  dil.  .     .  nil  0 

Liq.  ferri  perchlor lU  10 

Aqufe 5.i 

Misce.  (Charing  Cross.) 


(2)  R   Liq.  strychnise m  5 

Acidi  nitro-hydrochlor.  dil Til  5 

Liq.  ferri  perchlor tti  10 

Syr.  simplicis 5jss 

Mucilaginis 3j 

Aquae ad  §j 

Misce. 


71.  Mist.  Valerianse. 

R   Tinct.  Valerianae ni  48 

Infusi  Valerianae •5.1 

Misce.  (University  College.) 


72.  Mist.  Valerianae  Co. 

R   Tinct,  valerianse  amnion in  33 

Tinct.  camph.  co ni  10 

Sp.  ammon.  aromat ill  20 

Aquae  camphorae 5j 

Misce.  {University  College.) 

E  E 


418  FOEMUL^  AND  EECEIPTS. 


73.  Pigmentum  Collodii, 

R.   Collodii 5ss 

01.  ricini §j 

Misce. 

An  excellent  application  for  burns  or  scalds,  or  in  erysipelas. 


74.  Pigmentum  Cretae  Preparatae. 

R   Cretse  preparatae 5v 

01.  lini  (vel  olivse) §j 

Acidi  acetici  dil trt  10 

Misce. 

To  be  painted  on  tbe  part  with  a  camel's-hair  bnish.     For  burns 
or  scalds,  or  in  erysipelas. 


75.  Pigmentum  lodi. 

R    lodi gr.  10 

Sp.  setberis  nit ,     .     .     ,  5ij 

Sp.  vini  rect gss 

Collodii 3ij 

Misce.  • 

A  useful  application  for  cbilblains. 

76.  Pil,  Aloes  c.  Myrrha, 


R   Aloes  .     .     . 
Myrrbse  . 
Saponis  duri 
01.  carui 
Aquse 


gr.  2 
gr.  1 

gr.  1 

til  i 

q.  s. 


Misce.  {Guy's.) 

Tbis  pill,  under  tbe  name  of  Eufus'  or  Widow  Welch's  Pill,  is  a 
very  useful  and  popular  remedy  in  cases  of  chlorosis  and  irregular 
menstruation. 


77.  Pil.  Assafoetidae. 

R   Ext.  aloes  soc gr.  1 

Saponis  duri gr.  1 

Assafoetidse gr.  3 

Misce.  {Middlesex.) 


FORMULAE  AND   RECEIPTS.  419 


78.  Pil.  Colchici  Co. 

R    Ext.  colchici  acet gr.  2 

Pulv.  Doveri gr.  3 

Misce.  {Middlesex.) 


79.  Pil.  Ferri  Sulph,  et  Aloes. 

R   Ferri  sulph.  exsicc gr.  2 

Ext.  aloes  Barbad gr.  1 

Saponis  duri q.  s. 

Misce. 


80.  Pil.  Hydrarg.  lodidi. 

R    Hydrarg.  iodidi  vir. gr.  4 

Pulv.  opii gr.  i 

Micse  panis q.  s. 

Misce.  ( University  College.) 

81.  Pil.  Hydrarg.  lodidi  Rubri. 

R   Hydrarg.  iodidi  rubri gr.  -^^ 

Pulv.   glycerrbizse gr-  2 

Saponis  duri gr.  1 

Misce. 


82.  Pil.  Hydrarg.  Subchlor.  c.  Opio. 

R   Calomelanos gr.  1 

Pulv.  opii gr.  4 

Conf.  rosse  caninae q.  s. 

Misce.  {King's  College.) 


83.  Pil.  Nucis  Vomicae. 

R    Ext.  nucis  vomicae gr-  4 

Ext.  gentiange gr.  4 

Misce.  {London.) 

84.  Pil.  Podophylli. 

R    Podophylli  resinse •    gr.  | — 4 

Ext.  hyoscyami      ...  .     .     .  gr.  3 

Misce. 


To  be  taken  at  bedtime. 


E  K  2 


420  FORMULA  AND  EECEIPTS. 


85.  Fil.  Fotassii  lodidi. 

B-   Potassii  iodidi gr.  1 

Ext.  gentianse gr.  2 

Misce. 

These  pills  sliould  be  silvered. 

86.  Pil.  QuinisB  Co. 

R   Quinise  sulph gr.  1 

Ext.  conii gr-  3 

Misce.  (Middlesex.) 

87.  Pil.  Quiniae  c.  Ferro. 

R    Quinise  sulph gr.  2 

Eerri  sulph.       .     , gr.  2 

Ext.  gentianse gr.  1 

Misce.  (St.  Thomases.) 

88.  Fil.  Zinci  Valer.  Co. 

B-   Zinci  valer gr.  4 

Quiniae  sulph gr.  g 

Pil.  rhei  co gr.  1 

Ext.  gentianse gr.  2 

Misce.  _  (iyondon.) 

89.  TJng.  Calomelanos. 

5t   Hydrarg.  subchlor gr.  20 

Adipis §j 

Misce. 

90.  Suppositories. 

(1)  B    Pulv.  opii gr.  1—2 

Saponis  duri q.  s. 

Misce. 

(2)  B  Ext.  opii gr.  1—3 

Ext.  bellad gr.  4 

Olei  theobromai q.  s, 

Misce. 

(3)  B   Ext.  bellad gr.  2 

Plunibi  acet gr-  2 

Acidi  tannici gr.  4 

Olei  theobromse q.  s. 

(jErichsen.) 


FOEMUL^  AND  EECEIPTS.  421 


91.  Ointment  for  Bed-sores, 

Take  one  pound  of  mutton  suet  from  the  kidney.  Boil  it  in 
three  or  four  pints  of  water ;  strain  it ;  and,  when  cold,  it  will  float 
on  the  top  of  the  water.  Eub  it  between  the  hands  till  it  looks 
like  cold  cream ;  then  spread  it  with  the  palm  of  the  hand  very 
smoothly  upon  linen,  not  too  fine.  Be  careful  to  boil  the  suet  in  a 
perfectly  clean  saucepan,  and  that  there  is  no  salt  or  grit  along 
with  it. 

92.  Bread  Poultice. 

"  Scald  out  a  basin,  then  immediately  put  in  some  boiling  water, 
and  throw  into  it  coarsely  crumbled  bread.  Cover  the  basin  with 
a  plate.  When  the  bread  has  soaked  up  as  much  water  as  it  will 
imbibe,  drain  off  the  remainder,  and  there  will  be  left  a  light  pulp. 
Spread  it  a  third  of  an  inch  thick  on  folded  linen,  and  apply  it  when 
at  the  temperature  of  a  warm  bath."     (Abeenethy.) 


93.  Linseed  Meal  Poultice. 

"  Get  some  linseed  powder,  not  the  common  stuff  full  of  grit  and 
sand.  Scald  out  a  basin.  Pour  in  some  perfectly  boiling  water, 
throw  in  the  powder,  stir  it  round  with  a  stick  till  well  incorporated. 
Add  a  little  more  water  and  a  little  more  meal,  stir  again,  and 
when  it  is  two-thirds  the  consistency  you  wish  it  to  be,  beat  it  up 
with  the  blade  of  a  knife  till  all  the  lumps  are  removed.  If  pro- 
perly made  it  is  so  well  worked  together  that  you  might  throw  it  up 
to  the  ceiling  and  it  would  come  down  again  without  falling  into 
pieces.  It  is  in  fact  like  a  pancake.  Then  take  it  out  and  lay  it  on  a 
piece  of  soft  linen,  spread  it  the  fourth  of  an  inch  thick,  and  as  wide 
as  will  cover  the  whole  inflamed  part.  Put  a  piece  of  hog's  lard  in 
the  centre  of  it,  and  when  it  begins  to  melt  draw  the  edge  of  a  knife 
lightly  over  and  grease  the  surface  of  the  poultice."  (Abernethy.) 

94.  Mustard  Poultice. 

Mix  the  mustard  with  cold  water  and  knead  it  to  the  consistence 
of  putty.  Spread  it  the  eighth  of  an  inch  thick  upon  brown  paper, 
or  linen,  warm  it  before  the  fire,  and  apply  it  to  the  part  affected — 
putting  a  thin  piece  of  muslin  between  it  and  the  skin. 

95.  Bran  or  Hop  Poultice. 

Fill  a  bag  one-third  full  with  bran,  or  hop-flowers,  moistened  but 
not  thoroughly  wetted,  with  boiling  water.  Shake  the  bag  and 
hold  it  before  the  fire  till  it  is  thoroughly  hot,  and  then  apply  it  to 
the  affected  part. 


422  FORMULA  AND  KECEIPTS. 


96.  Bryony  Poultice  for  Bruises. 

A  poullice  made  of  black  bryony  root  (deprived  of  its  bark  and 
finely-scraped)  and  bread  crumbs,  or  flour,  should  be  inclosed  in  a 
muslin  bag,  and  applied  over  the  injured  part.  It  will  generally 
cause  the  ecchymosis  to  disappear  within  twenty-four  hours. 
(Tyrrell  on  "Diseases  of  the  Eye,"  i.  200.) 


97.  Ice  Poultice. 

Take  of  linseed  meal  a  sufficient  quantity  to  form  a  layer  from 
three-quarters  to  an  inch  thick,  and  spread  it  on  a  cloth  of  proper 
size.  Upon  this,  at  intervals  of  an  inch  or  more,  place  lumps  of 
ice  the  size  of  a  big  marble,  then  sprinkle  them  over  with  the  meal, 
cover  with  another  cloth,  folding  in  the  edges  to  prevent  the  escape 
of  fluid,  and  apply  the  thick  side  to  the  surface  of  the  wound. 
(Maisonneuve  ) 


98.  To  Dress  a  Blister. 

When  sufficiently  raised  carefully  draw  off  the  blister ;  and  where 
you  see  the  skin  overhanging,  snip  it  in  three  or  four  places  with 
sharp-pointed  scissors,  having  first  taken  care  to  place  a  clean  soft 
rag  below  the  blister  to  catch  the  water  that  runs  from  it.  Be  very 
careful  not  to  snip  anything  but  the  raised  skin,  or  you  will  have  a 
sore  afterwards.  When  the  water  has  ceased  to  flow,  apply  a 
bread-and- water  poultice.  When  the  poultice  comes  off,  spread 
some  lard  or  cold  cream  on  a  clean  piece  of  linen  rag,  and  lay  it 
over  the  part. 

99.  White  Wine  Whey. 

Boil  half  a  pint  of  new  milk  with  a  dessert-spoonful  of  sifted 
sugar.  Pour  in  a  wine-glassful  of  sherry  or  Madeira.  To  be  taken 
quite  hot. 

100.  Egg-Flip. 

Beat  the  yolks  of  two  new-laid  eggs  with  a  dessert-spoonful  of 
sifted  sugar,  and  stir  into  a  quarter  of  a  pint  of  boiling  white  wine 
or  brandy-and-water.     To  be  taken  hot. 


101.  Treacle  Posset. 

Boil  half  a  pint  of  new  milk,  and  while  boiling  stir  in  two  table- 
Bpoonfuls  of  treacle.     To  be  taken  hot. 


FORMULA  AND  RECEIPTS.  423 


102.  Linseed  Tea. 

Put  one  ounce  of  linseed  and  half  an  ounce  of  Spanish  liquorice 
into  a  jug;  pour  over  them  a  pint  and  a  half  of  hoiling  water, 
cover  close,  and  let  it  stand  till  quite  cold.  Strain  off,  To  be 
made  hot  as  wanted  or  taken  cold. 

103.  Imperial  Drink 

Put  half  an  ounce  of  cream  of  tartar,  the  juice  of  one  lemon,  and 
two  table-spoonfuls  of  sifted  sugar  into  a  jug,  and  pour  over  them 
one  quart  of  boiling  water.     Cover  till  cold. 

104.  Tamarind  Drink. 

Take  a  quarter  of  a  pint  of  tamarinds.  Pour  over  them  one  quart 
ol  boiling  water.  Sweeten  to  taste.  Cover,  and  let  it  stand  for  an 
hour. 

105.  Meat  Paste. 

Take  a  small  piece  of  raw  meat  perfectly  free  from  fat  (beef, 
nmtton,  or  chicken),  shred  it  as  fine  as  possible,  and  rub  it  through 
a  sieve  so  as  to  form  a  smooth  paste.  Mix  apiece  the  size  of  a  pea 
with  a  little  cream  and  sugar.  To  be  given  frequently.  In 
cases  of  extreme  exhaustion  from  diarrhoea  or  other  causes  it  is  very 
useful,  specially  for  children.  It  may  be  given  as  a  sandwich 
between  thin  pieces  of  bread,  if  preferred. 

106.  Pounded  Meat. 

Take  some  chicken  partly,  but  not  thoroughly  boiled,  clear  it 
perfectly  from  skin,  shred  it  as  fine  as  possible,  beat  it  to  a  paste 
in  a  mortar  with  a  little  of  the  liquor  it  was  boiled  in.  Simmer  it 
gently  for  a  few  minutes  with  as  much  of  the  liquor  as  will  bring  it 
to  the  thickness  of  gruel. 

107.  Essence  of  Beef. 

Cut  into  small  slices  a  pound  of  beef  from  the  rump  or  sirloin, 
free  from  fat,  put  it  in  a  stone  jar  with  a  cover,  without  any 
water.  Fasten  the  cover  down  well  with  a  double  bladder.  Stand 
the  jar  in  a  saucepan  of  hot  water  and  simmer  for  six  hours.  When 
you  take  it  out  you  will  find  about  a  tea-cupful  of  the  strongest 
beef  juice.  Give  at  first  a  tea-spoonful  at  a  time.  It  is  palatable 
either  hot  or  cold,  and  so  light  that  it  will  remain  on  the  stomach 
when  even  toast-and-water  is  rejected.  If  preferred  as  a  jelly,  a 
little  isinglass  may  be  put  in  the  jar  at  first  with  the  meat.  Salt 
must  be  added  afterwards. 


424  FORMULA  AND  EECEIPTS. 


108.  Beef  Tea. 

1.  The  beef  must  be  very  fresb.  Take  four  pounds  of  tbe  uppei' 
side  of  the  round,  cut  it  into  small  pieces,  leave  out  every  bit  o " 
fat,  put  it  into  a  jar  with  a  salt-spoonful  of  salt  and  three  pints  of 
cold  water.  Tie  it  closely  down,  place  it  in  a  saucepan  of  water 
and  let  it  boil  gently  for  five  hours.  The  precaution  of  passing  i, 
piece  of  stale  crumb  of  bread  over  the  surface,  before  serving,  shouh. 
be  carefully  observed,  lest  any  fat  should  remain. 

2,  Take  one  pound  of  raw  beef,  free  from  fat  and  bone.  Minc( 
the  meat  very  fine.  Pour  over  it,  into  a  stone  or  china  vessel 
eight  ounces  of  distilled  water  to  which  has  been  added  five  drops 
oi"  strong  hydrochloric  acid.  Let  it  stand  for  two  hours ;  ther^ 
strain  thi'ough  muslin,  adding  two  ounces  moi'e  water  to  help  itj 
through.     Season  with  one  tea-spoonful  of  salt. 

It  is  best  to  give  it  cold  ;  but  if  wanted  warm,  it  must  be  put 
in  a  cup  and  placed  in  a  basin  of  hot  water.  It  must  not  be 
cooked. 

109.  Veal  Tea. 

1.  Cut  up  into  small  pieces  three  pounds  of  lean  veal,  put  it 
into  an  enamelled  saucepan  with  three  pints  of  cold  water  and  a 
salt-spoouful  of  salt.  When  it  boils  skim  very  carefully.  Simmer 
for  three  hours.  Strain  into  a  basin,  and,  when  cold,  remove 
every  particle  of  fat.  When  required  pour  half  a  pint,  while  boil- 
ing, on  to  a  tea-spoonful  of  arrowroot  which  has  been  mixed  with 
a  desert-spoonful  of  the  cold  veal  tea. 

2.  Creme  cforge. — Wash  half  an  ounce  of  pearl  barley  in  cold 
water.  Strain,  and  let  it  stand  in  one  pint  of  fresh  water  for  an 
hour.  Put  half  a  pound  of  veal  cutlet,  free  from  skin  and  fat, 
into  a  pan  with  the  barley  and  water  and  a  quarter  of  a  salt-spoon- 
ful of  salt.  Simmer  very  gently  for  two  hours.  Strain ;  set  aside 
the  liquor ;  pound  the  meat  very  smooth  in  a  mortar ;  rub  it 
through  a  liair-sieve,  using  all  the  liquor  to  help  it  through.  Add 
half  a  gill  of  cream,  and  a  little  salt.    Warm,  and  serve. 

110.  Chicken  Broth. 

Cut  up  a  fowl,  and  break  the  leg-bones.  Put  it  into  a  stewpan 
with  a  quart  of  cold  water,  a  tea-spoonful  of  salt,  and  the  same 
quantity  of  loaf  sugar.  Boil  gently,  skimming  constantly,  for 
four  hours.  Then  strain  into  a  basin.  When  cold,  take  off  the 
fat.     When  required  for  use,  warm  a  cupful. 

111.  Chicken  Jelly. 

Take  a  whole  chicken,  cut  it  up,  put  it  into  ajar,  pour  over  it 
a  tea-cupful  of  cold  water,  tie  it  down  very  closely  with  a  bladder  , 


FOEMUL^  AND  RECEIPTS.  425 

place  the  jar  in  a  saucepan  of  water,  and  boil  quickly  for  nine 
hours.  Strain  the  liquid  through  a  sieve.  When  it  is  cold, 
remove  the  fat.     A  most  nourishing  and  agreeable  jelly  remains. 

112.  Port  Wine  Jelly. 

Take  two  ounces  of  isinglass,  two  ounces  of  gum  arabic,  two 
pints  of  port  wine,  and  put  them  into  a  jar  with  a  lid.  Put  the 
jar,  well  covered,  into  a  stewpan  of  boiling  water,  and  place  it  on 
a  hot  plate,  or  over  a  slow  fire,  till  it  is  quite  dissolved.  Then  pour 
into  small  moulds  and  let  it  cool. 

113.  Port  Wine  Lozenges. 

Take  two  ounces  of  isinglass,  one  ounce  of  gum  arabic,  two 
ounces  of  sugar  candy,  and  one  pint  of  port  wine.  Set  these  in 
a  jar  of  cold  water,  and  let  it  simmer  by  the  fire,  stimng  it  with 
a  clean  wooden  spoon  till  quite  dissolved.  When  it  cools,  it  will 
harden  into  a  jelly,  and  may  be  cut  out  in  squares. 

114.  Isinglass  and  Eggs. 

Boil  the  third  of  an  ounce  of  the  best  isinglass  and  a  dessert- 
spoonful of  sifted  loaf  sugar  in  the  thii-d  of  a  pint  of  water. 
When  quite  dissolved,  add  three  drops  of  orange  flcwer  water,  and 
the  yolks  of  two  new-laid  eggs  well  beaten.  Boil  up  for  one 
minute,  strain  through  muslin  into  small  mould,  and  serve  when 
cold. 

115.  Flour  Gruel. 

Tie  up  one  pound  of  flour  tightly  in  a  cloth,  place  it  in  a  sauce- 
pan of  cold  water,  and  boil  it  for  four  or  five  hours.  When  taken 
out  it  will  be  a  hard  ball.  Pare  away  the  outer  rind.  When 
needed  for  use  scrape  off  a  sufficient  quantity  and  mix  with 
boiling  milk  to  the  thickness  of  gruel. 

An  excellent  food  in  diarrhoea. 


116.  Soupe  a  Vin. 

Take  two  or  three  shoes  of  bread  from  which  the  crust  has 
been  cut.  Toast  them,  and  lay  them  in  a  soup  plate,  dusting 
each  piece  over  with  sifted  white  sugar.  Then  pour  over  all  about 
a  tumblerful  of  hot  wine  and  water.  Port  wine  or  claret  is  the 
most  suitable  for  the  purpose. 


INDEX. 


\  BDOMEN,  peBetrating  wounds  of  the 
-'-^         ,,  tapping  the 

Abscess,  acute  . 
chronic 
cold     . 
iliac    . 
lumbar 
psoas  . 
Acromion,  fracture  of  the 
Acupressure 
Adenitis  . 
Adenoid  tumour 
Adhesive  inflammation 
Albugo     . 
Amaurosis 
Amputations 
Amussat's  operation 
Anaesthesia  (local) 
Ansesthetics 

Angular  curvature  of  the  spine 
Ankylosis 
Aneurysm 

, ,         varieties  of 
,,         treatment  of 
,,         by  anastomosis  (nsevu 
Animation,  suspended 
Ankle,  amputation  at  the 
dislocation  at  the 
excision  of  the 
fractures  about  the 
sprained 
strapping  the 
Anthrax  (carbuncle)  . 
Antiseptic  dressings  . 
Antrum,  abscess  of  the 
Anus,  artificial 

,,      fissure  of  the    . 
„      imperforate 


66,  279 

.  277 

.  12 

.  12 

.  12 

.  218 

.  218 

.  218 

.  142 

.  51 

.  204 

.  274 

.  10 

.  237 

.  246 

.  391 

.  282 

.  369 

.  366 

.  215 

.  179 

.  196 

.  196 

.  198 

.  200 

.  76 

.  399 

.  193 

.  390 

.  167 

.  104 

.  105 

.  102 

.  14 

.  254 

.  283 

.  297 

.  296 


428 


INDEX. 


PAGE 

Aphthous  ulcers        ....... 

.     258 

Apnoea     ......... 

.      77 

Arcus  senilis 

.     239 

Arm,  amputation  of  the  fore-    ..... 

.     394 

jj        _     „              „      upper 

.     394 

,,     slings  for  the     ....... 

143,  145 

„     trough  for  the  ....... 

.     149 

Arteria  dorsalis  pedis,  ligature  of  the  .... 

.     386 

Arteries,  degeneration  of   . 

.     195 

,,       ligature  of  .         .          .... 

.     378 

Arteritis  ......... 

.     194 

Arthritis           ........ 

.     175 

„         chronic  rheumatic        ..... 

.     176 

Artificial  anus  ........ 

.     283 

„         pupil     _ 

.     242 

„         respiration  ....... 

.       78 

Asphyxia          ........ 

.       77 

Aspirator,  the  pneumatic  ...... 

.       14 

Astragalus,  dislocation  of  the      ..... 

.     193 

Atrophy            .....          ... 

.       23 

Axillary  artery,  ligature  of  the  ..... 

.     382 

,,        bandage       ....... 

.     139 

"D  ALANITIS . 

^^   Bandage,  capitellum 

325,  339 

.     211 

,         compound  axillary         .... 

.     139 

,         Esmarch's    ....          .         . 

.     365 

,         for  a  stump          ..... 

.     397 

for  bleeding 

.     373 

,         for  both  breasts    ..... 

.     272 

,         for  one  breast        ..... 

.     271 

,         for  supporting  the  scrotum     . 

.     332 

,         for  the  chin          ..... 

.     137 

,         for  the  hand  and  arm    .... 

152,  153 

for  the  head          ....       209, 

210,  211 

,        for  the  knee          ..... 

.     174 

,         for  the  leg 

100,  101 

,        for  transverse  wounds  of  the  neck  . 

.     267 

,        for  wiy-neck          ..... 

.     266 

,         four-tailed    ....          .         . 

137,  210 

,         many-tailed          .         .          .        ■  . 

.     398 

,         nodose          ...... 

.       50 

,        prepared  with  starch,  plaster  of  Paris,  &c. 

.     129 

,        six-tailed      ...... 

.     211 

,        spica   ....... 

.     347 

Barbadoes  leg   .......         . 

.     336 

Bellocq's  canula         ....... 

.     251 

Bladder, 

acute  inflammation  of  the      .... 

.     314 

INDEX. 


429 


Bladder,  cancer  of  the 

,,        chronic  inflammation  of  the  . 
,,        stone  in  the 
, ,        to  tie  a  catheter  in  the  male 
„  „  female 

Bleeding,  bandages  for 
Boil  (furunculus) 
Bone,  diseases  of 
Bony  tumours  . 
Brachial  artery,  ligature  of  the 
Brain,  compression  of  the  . 

,,       concussion  of  the     . 

,,       traumatic  inflammation  of  the 

,,       wounds  of  the 
Breast,  acute  inflammation  of  th 

,,       bandaging  the 

,,       excision  of  the 

, ,       hypertrophy  of  the 

, ,       malignant  tumours  of  the 

,,       strapping  the 
Bronchi,  foreign  bodies  in  the 
Bronchocele  (goitre) 
Bruises     . 
Bubo 

Bubonocele 
Bunions  . 
Bums 

Bursse,  inflammation  of  the 
Bursal  abscess  . 

pALCULUS,  renal 
^         ,,  salivary 

, ,  vesical 

Callissen's  operation  . 
Cancer      .... 

,,      colloid    . 

,,       encephaloid  or  medullary 

, ,      epithelial 

,,       melanotic 

, ,      of  the  nasal  cavity 

, ,       of  the  rectum 

, ,      rodent    . 

, ,       scirrhous 

,,       treatment  of 

,,       villous    . 
Cancrum  oris 
Capitellum  bandage 
Carbuncle  (anthrax) 


PAGE 

316 
315 
319 
310 
311 
373 
101 
110 
35 
383 
207 
206 
208 
211 
272 

271,  272 
277 

270,  274 
275 
273 
265 
268 
56 
346 
285 
363 
72 
109 
111 

318 

256 

319 

282 

36 

41 

38 

40 

42 

253 

303 

223 

37 

43 

41 

260 

211,  212 

.  102 


430 


INDEX. 


Carcinoma 

Caries      .... 

.,      of  the  cervical  vertebrae 
Carotid  artery,  ligature  of  the  common 
Carte's  tourniquet 
Cartilages,  loose 

,,         ulceration  of 
Castration 

Cataract  .... 
Catheter  (in  male)  to  tie  in  a 

,,       (in  female)       ,, 
Catheterism 
Cauterization    . 
Caustics  in  cancer 
Cellulitis  .... 
CepbalhEematoma  (blood  tumour  of  scalp) 
Charbon  (malignant  pustule) 
Chelis  (cheloid  tumour) 
Chest,  tapping  the     . 
Chilblains 

Chimney-sweep's  cancer  of  the  scrotum 
Chin,  four-tailed  bandage  for  the 
Chloroform,  administration  of 
Cholesterine 
Chopart's  operation  . 
Chordee    .... 
Chronic  mammary  tumour 

,,       rheumatic  arthritis 

,,      synovitis 
Cicatrization 
Clavicle,  dislocation  of  the 

, ,       fracture  of  the 
Cleft  palate 
Clove-hitch 
Club-foot 
Cold,  effects  of 
Collapse  (shock) 
CoUes's  fracture  of  the  radius 
Colloid  cancer  . 
Colotomy 

Common  lined  splints 
Compression  of  the  brain  . 
Compressors  for  the  aorta 
Concussion  of  the  brain 
Condylomata  (warts:  mucous  tubercles) 
Congestion 

Conjunctiva,  foreign  bodies  in  the 
,,  granular 


INDEX. 

431 

PAGE 

Conjunctivitis,  purulent     .......     231 

,,             simple        .... 

.     230 

Contraction  of  the  fingers  .... 

.     357 

Contusions  of  the  scalp     .... 

.     209 

Cornea,  abscess  of  the        .... 

.     236 

, ,       conical  ...... 

.     238 

,,        foreign  bodies  in  the 

.     246 

,,        inflammation  of  the 

.     235 

opacity  of  the         .... 

.     237 

„         ulcer  of  the   ..... 

.     236 

Corns        ....... 

.     362 

Cretinism           ...... 

.     268 

Crutches  ....... 

.     170 

Cupping 

7 

Curvatures  of  the  spine     .... 

.     214,  215 

Cutaneous  ulcers        ..... 

95 

Cut-throat 

.     267 

Cystitis     ....... 

314,  315 

T^EGENERATION  of  arteries 

-^     Delirium,  traumatic  .... 

.     195 

.       81 

Determination  of  blood      .... 

1 

Dextrine  bandage       ..... 

.     129 

Diathesis  in  calculous  disease 

.     317 

Diseases  of  joints        ..... 

171 

Dissection  T?ounds      ..... 

70 

Dislocations        ...... 

.     183 

,,          signs  of  . 

184 

,,          treatment  of     . 

184 

,,          varieties  of       ....         . 

183 

Dislocation  of  the  lower  jaw 

185 

,,             ,,      clavicle  .... 

186 

,,              „      scapula  .... 

186 

,,              ,,       shoulder 

187 

,,             ,,      elbow     ..... 

189 

,,             ,,       wrist      ..... 

189 

„              „       hand       .... 

190 

„      hip          . 

190 

,.             „       patella    .... 

192 

,.             .,       semilunar  cartilages 

192 

„              ,,      knee-joint        .... 

193 

,,       ankle     ..... 

193 

,,              ,,      astragalus       .... 

193 

Distorted  toes    ....... 

363 

Double  inclined  plane         ..... 

157 

Dressings          ....... 

369 

,,         for  a  stump         ..... 

394 

Drowning           ....... 

77 

432 


INDEX. 


Duct,  obstruction  of  the  nasal     . 
Dupuytren's  splint     . 

Tj^  AR,  accumulation  of  wax  in  the 
-^  „     foreign  bodies  in  the 

,,     polypus  of  the 
Ecraseur,  use  of  the 
Ectropion 

Effects  of  heat  and  cold 
Effusion,  inflammatory 
Elbow,  dislocations  of  the 

,,      excision  of  the 
Elephantiasis  of  the  leg 
Embolism,  effects  of 
Encephalitis,  traumatic 
Encephaloid  cancer 
Enchondroma 

Encysted  tumours  of  the  eyelids 
Entropion 
Epididymitis     . 
Epiphora 
Epispadias 
Epistaxis 
Epithelioma 

,,         of  the  lip 
„         of  the  tongue 
Epulis 
Equinia    . 
Erysipelas 

,,        of  the  fauces 

,,        of  the  scalp 

,,        of  serous  membranes 

„         phlegmonous 
Ether  as  an  anaesthetic 
Excision  of  joiats 
Exostosis 

Extravasation  of  urine 
Eye,  diseases  of  the 
Eyeball,  tumours  of  the 
,,        wounds  of  the 
Eyelids,  encysted  tumours  of  the 

FALSE  joints 
Farcy        .... 
Fatty  tumours 
Female,  stone  in  the 
Femoral  artery,  ligature  of  the  superficial 
Femur,  fractures  of  the      . 


INDEX. 


433 


PAGE 

Femur,  fractures  of  the  neck  of  the    .... 

154 

Fever,  surgical  or  traumatic       ...... 

80 

Fibrous  tumours         ....... 

31 

Fibula,  fractures  of  the      ...... 

165 

Fingers,  amputation  of  the          ..... 

392 

,,        contraction  of  the          ..... 

357 

,,        fractures  of  the  bones  of  the  .... 

152 

Fissure  of  the  anus    ...          .... 

297 

Fistula  in  ano            ....... 

301 

„      in  perineo       .          .          .          .          . 

312 

,,      lactirymalis   ....... 

229 

„      salivary          ....... 

220 

,,      vesicovaginal         ....... 

337 

Flat-foot 

360 

Forcipressure.  arrest  of  haemorrhage  by       .          .          . 

53 

Fore-arm,  amputations  of  the      ..... 

394 

,,          fractures  of  the            ..... 

148 

Foreign  bodies  in  the  ear             ..... 

250 

,,           ,,      in  the  eye            ..... 

246 

,,           ,,       ia  the  larynx,  trachea,  and  bronchi 

265 

,,            ,,       in  the  pharynx              .          .          .          .          . 

265 

Fractures,  greenstick          ...... 

120 

,,         complicated       ...... 

131 

,,          compound          ...... 

132 

,,         indications  of     .         .          .         .         .         .         . 

121 

,,         ununited             ....... 

133 

,,         treatment  of      ......         . 

122 

,,          union  of             ...... 

121 

,,         varieties  of        ......         . 

120 

Fractures  of  the  skull          ...... 

134 

„         ,,         bones  of  the  face         .... 

136 

I'il^'s 

137 

„         ,,         clavicle      ...... 

139 

„         ,,         scapula      ...... 

.     141 

„          „         humerus    ...... 

.     142 

„         „         fore-arm     ...... 

.     148 

„         ,,         metacarpal  bones  and  phalanges 

152 

pelvis 

.     153 

„         „         femur 

.     153 

„         patella       .         .         ... 

.     161 

„         »         leg    • 

.     164 

,,       about  the  ankle-joint 

167 

,,       of  the  tarsal  and  metatarsal  bones 

170 

Frostbite 

75 

Fungus  hsematodes 

38 

Furunculus  (boil)        ........ 

101 

F  F 


434 


INDEX. 


p  ANGLION,  simple 


compound 


Gangrene,  hospital 

„  inflammatory 

,,  senile 

Gangrenous  stomatitis 
Gastrotomy 
Genu-valgum 
Glanders 

Glands,  inflammation  of  the  lymphatic 
Glandular  tumours    . 
Glaucoma 
Gleet 

Goitre  (bronchocele)  . 
Gonorrhoea 
Gonorrhoeal  ophthalmia 

„  rheumatism 

, ,  warts 

Graduated  compress 
Granular  conjunctiva 
Granulation 
Gunshot  wounds 
Gutta-pei'cha  splints  . 

TT^MORRHAGE,  arrest  of 
-*-^  ,,  capillary 

,,  secondary  arterial 

, ,  venous 

Hsemorrhaoic  diathesis 
Haemorrhoids     . 
Hseraatocele 
Hand,  dislocations  of  the 

,,       fractures  of  the 
Hanging,  death  by 
Hare-lip 

Head,  bandages  for  the 
Healing  by  scabbing 
Heat,  effects  of 
Hectic  fever 
Hernia 

„        congenital 

,,        femoral 

„        inc-ircerated 

,,        infantile 

,,        inguinal 

,,        irreducible    . 

,,        strangulated 
testis  , 


PAGE 

107 

107 

99 

18 

20 

260 

282 

361 

70 

204 

29 

244 

341 

268 

338 

233 

341 

341 

60 

234 

22 

62 

131,  143 

48 
55 
54 
55 
55 
297 
330 
190 
152 
77 
220 
209-211 
22 
72 
83 
283 
285 
286 
285 
285 
285 
284 
291 
334 


INDEX. 


43; 


Ilernia,  umbilical 

Iley's  operation 

Hip,  amputation  at  the 
,,     diseases  of  the   . 
,,     dislocations  of  the 
,,     excision  of  the 

Hordeolum  (stye) 

Hospital  gangrene 

Housemaid's  knee     . 

Humerus,  amputations  through  the 

,,         fractures  of  the  upper  end  of  the 

,,  ,,  ,,      shaft  of  the 

,,  ,,  ,,       lower  end  of  the 

Hydrocele 

, ,  congenital 
,,  encysted  . 
,,         of  the  cord 

Hydrophobia     . 

Hydrops  articuli  (hydrarthrosis) 

Hyperasmia  (local) 

Hypertrophy     . 

,,  of  the  breast  . 

,,  of  the  scrotum 

Hypopyon 

Hypospadias     . 

Hysteria  .... 

TCHORiEMIA 

-*-     Iliac  artery,  ligature  of  the  external 

Imperforate  anus 

Incisions    .... 

Inflammation 

,,  acute 

,,  adhesive 

, ,  chronic . 

,,  causes  of 

,,  events  of 

„  local  effects  of 

,,  spread  of 

,,  suppurative  . 

,,  terminations  of 

,,  treatment  of . 

„  varieties  of    . 

Interrupted  splints     . 
Intestinal  obstruction 
Intussusception 
Iritis         .... 
..     rheumatic 


F  F  2 


43G 


INDEX. 


Iritis,  sypMlitic 
Issues ,  application  of 

TAW,  dislocation  of  the  lower 
^    „     fracture  ,,  ,, 

,,     tumours  ,,  ,, 

,,  „        of  tLe  upper 

,,     excision  of  the  upper 
Joints,  diseases  of 
,,       excision  of 
„       loose  cartilages  in   . 
„       scrofulous  disease  of 
wounds  of 

KERATITIS 
Kiduey,  calculus  in  the 
Knee-joint,  amputation  at  the 
,,  dislocation  of  the 

,,  excision  of  the 

Knock-knee 


T  ACHEYMAL  fistula     . 
-^  „  sac,  inflammation  of  the 

,,  duct,  obstruction  of  the 

Laryngotomy     .... 
Laryngo-tracbeotomy 
Larynx,  foreign  bodies  in  the     . 
Lateral  curvature  of  the  spiue    . 
Leg,  amputation  of  the 

,,     bandage  fnr  the 

,,    fractures  of  the 
Leucoma  .... 

Leucocytosis      .... 

Ligature  of  arteries 

Lingual  artery,  ligature  of  the    . 

Lip,  epithelioma  of  the 

Lipoma    ..... 

Lippitudo  .... 

Lister's  antiseptic  method  of  dressing 
Liston's  long  splint    . 
Lithotomy  .... 

Litholrity  .... 

Local  anaesthesia 

Local  hyperaemia 

Loose  cartilages  in  joints    . 

Lumbar  abscess 

Lupus      ...... 

Lymphatic  glands,  inflammation  of  the 


ids 


INDEX. 


437 


Lympliatic  glands,  cancer  of  the  . 
Lymphatics,  hitiammation  of  the  . 

IVrALFORMATIONS,  congenital 

-^^■'-     Malgaigne's  hooks     . 

Malignant  pustule 

Many-tailed  bandage  . 

Mclutyre's  splint 

Melanosis  (melanotic  cancer) 

Metacarpal  bones,  fractures  of  the 

Metacarpo-phalangeal  joint,  amputation  at  the 

Metatarsal  bones,  fractures  of  the 

MoUities  ossium  (osteomalacia) 

MoUuscum  contagiosum 

Morphia,  subcutaneous  injection  of  (F.  10) 

Mortificadou 

„  treatment  of 

,,  varieties  of 

Moxa,  the  . 
Mucocele   . 
Mucous  tubercles 
Muscles,  rupture  of    . 

"^^VUS  (aneurysm  by  anastomosis) 
-'-^      Nasal  bones,  fracture  of  the 
Nasal  cavity,  cancer  of  the  . 
Nasal  duct,  obstruction  of  the 
Nathan  Smith's  antei'ior  splint    . 

Nebula 

Neck,  wry  (torticollis) 
Necrosis    ..... 
Neuralgia  ..... 
Neuroma  ..... 
Nitrous  oxide  as  an  ansesthetic 
Nodes,  syphilitic 
Nodose  bandage  .  . 

Nose,  polypus  of  the  . 

kBSTRUCTION  of  the  nasal  duct 
,,  ,,      bowels 

(Esophagus,  stricture  of  the 
Oidium  albicans 
Olecranon,  fracture  of  the 
Onychia,  simple 

,,         malignant  . 
Onyx 
Operations  in  general 

constitutional  treatment  after 


PAGE 

205 

204 

23 

lt)3 

71 

398 

1G6 

41,42 

152 

393 

I7O 

113 

226 

404 

17 

19 

18 

374. 

229 

350 

103 

200 
136 
253 
229 
159 
237 
26fi 
117 
205 

31 
369 
352 

50 
252 

229 
281 
263 
258 
148 
354 
355 
236 
364 
372 


438 


INDEX. 


Ophthalmia  tarsi  (tinea  ciliaris) 

,,  catarrhal 

„  gODorrhceal 

„  neonatorum     . 

„  strumous 

Opisthotonos  . 
Orbital  nsevus  . 
Orchitis,  acute 

„         chronic 
Osteitis  (inflammation  of  bone) 
Osteo-sarcoma   . 
Otorrhoea 
Ovarian  disease 
Ovariotomy 
Ozaena      .... 

PARACENTESIS  abdominis 
-*-  ,,  thoracis 

Paraphimosis    . 
Paronychia  (whitlow) 
Patella,  dislocation  of  the  . 

,,  fracture  of  the 
Pelvis,  fractures  of  the 
Penis,  amputation  of  the 

,,     cancer  of  the    . 
Perineum,  ruptured  . 
Perinea]  section 
Periostitis 
Peritonitis 
Petit's  tourniquet 
Phalanges,  fracture  of  the 
Pharynx,  foreign  bodies  in  the 
Phimosis 
Phlebitis 

PirogoflF's  operation    . 
Plaster-of-Paris  splints 
Poisons,  wounds  by  irritant 
Polypus    .... 

,,      of  the  ear 

,,       of  the  nose    . 
Popliteal  artery,  ligature  of  the 
Pott's  fracture  . 
Prolapsus  recti 
Propto-sis  (exophthalmos)   . 
Prostate,  abscess  of  the 

,,         enlargement  of  the 

,,         inflammation  of  the 
Psoas  abscess    . 


INDEX. 


439 


Pterygium 
Ptosis 

Pupil,  artificial 
P.va3iiiia   . 
Pyrexia     . 


Q 


UlNSY  (cyuanche  tonsillaris) 


"pADICrS,  Colles's  fracture  of  tlie 

-L^     ,,  fracture  of  the 

Radial  artery,  ligature  of  the 

Ranula 

Rectum,  cancer  of  the 

,,         prolapse  of  the 

, ,         stricture  of  the 

,,         ulcer  of  the 
Repair,  processes  of  . 
Respiration,  artificial 
Retention  of  urine     . 
Ribs,  fracture  of  the  . 
Rickets  (rachitis) 
Rodent  ulcer  or  cancer 
Rupia,  syphilitic 
Rupture  of  muscles  or  tendons 
Ruptured  perineum    . 

O  ALIVARY  calculus 
^         ,,  fistula  . 

Sarcocele,  cystic 
Sarcoma,  myeloid 

,,  round- celled 

,,         spindle-celled 
Sayre's  plaster  jackets 
Scalds 
Scalp,  contusions  of  the 

„       wounds  of  the   . 
Scapula,  dislocation  of  the 

,,         fracture  of  the 
Scarification 
Sclerotitis  . 
"  Scotc's  dressing" 
Scrofula 
Scrofulous  diseases  of  joints 
Scrotum,  bandages  for  supporting  the 

,,  cancer  of  the 

,,         oedema  of  the 

„         hypertrophy  of  the 


PAGE 

235 
228 

242 

89 

2 

262 


150 
149 
383 
256 
303 
299 
302 
297 
21 
78 
303 
137 
112 
41,  223 
349 
103 
338 

256 

220 

334 

33 

32 

32 

216 

72 

209 

210 

186 

141 

7 

239 

173 

44 

178 

332 

337 

335 

335 


uo 


INDEX. 


Sebaceous  tumours  .  .  .  . 
Semilunar  cartilages,  dislocation  of  the 
Septicseiaia  (pyasmia) . 
Senile  gangrene 
Setons,  ajjplication  of 
Shock  (collapse) 
Shoulder,  amputation  at  the 
,,  dislocation  of  the 
,,  excifion  of  the 
Signoroni's  tourniquet 
Skin-grafting     . 

,,     ulcers  of  the 
Skull,  fractures  of  the 
Sloughing  phagedtena 
Spica  bandages 
Spina  bifida 

Spinal  cord,  injuries  of  the 
Spine,  angular  curvature  of  the 

,,      lateral  ,,         ,, 

,,      fracture  of  the 
Splay  foot 
Splints     . 

, ,  Bavarian 

,,         gutta-percha 
Sprains    . 
Sprained  ankle 
Squinting  (strabismus) 
Staphyloma 

Staphyloraphy  (velosynthesis) 
Starch- bandage 
Stillicidium  lachrymarum 
Stomach-pump,  use  uf  the 
Stone  in  the  bladder 
Strabismus  (squinting) 
Strait- waistcoat 
Strangulated  hernia 
Strapping  an  ulcer 
,,         the  ankle  . 
„         the  testicle 
Stricture  of  the  ossophagu 
,,         ,,  rectum 

,,  ,,         urethra 

Struma  (scrofula) 
Stye  (hurdeoluui) 
Styptics 

Subclavian  artery,  ligature  of  th 
Su[)puratiou 
Suraicdl  ftver    . 


INDEX. 


441 


Suspended  animation 
Sutiu'es,  varieties  of  . 
Syncope  .... 

Syme's  amputation  at  the  ankle 
Synovitis,  acute 

,,  chronic 

Syphilis  .... 

,,        infantile 

,,        secondary 

rpALlPES  (clul3-foot)       . 
-*-      Tapping  the  ahdomen 
,,         the  chest     . 
Tarsal  bones,  iractures  of  the     . 
Tarsal  cysts      .... 
Tarsus,  amputation  through  the 
T-bandage         .... 
Teale's  amputation    .         .         . 
Temperature  chart     . 
Ten  do  Achillis,  rupture  of  the 
"j-eno- synovitis 
Testicle,  acute  inflammation  of  the 

„        chronic  inflammation  of  the 

,,        cancer  of  the 

„       excision  of  the  (castration) 

,,       scrofulous  disease  of  the 

,,       strapping  the 
Tetanus 

Thigh,  amputation  through  the 
Throat,  wounds  of  the 
Thrombus 
Thumb,  amputation  of  the 

,,        dislocation  of  the 
Tibia,  fractures  of  the 
Tibial  artery,  ligature  of  the  anterior 
,,      _  ,,  _  „         ,,       posterior 

Tinea  ciliaris  (ophtlialmia  tarsi) 
Toe,  ulceration  of  the  great 
Toes,  amputation  of  the 
Tongue,  epithelioma  of  the 

„       -tie      ._ 

,,       ulceration  of  the  . 
Tonsil,  acute  inflammation  of  the 
,,        chronic  enlargement  of  the 
,,        excision  of  the 
Torsion,  arrest  of  hgemorrhage  by 
Torticollis  (wry -neck) 
Trachea,  foreign  bodies  in  the 


442 


INDEX. 


Tracheotomy     . 
Traumatic  encephalitis 
Traumatic  fever 
Trichiasis 
Trismus    . 
Trusses  for  hernia 
Tuberculosis 
Tumours  . 

,,        adenoid 

,,        atheromatous 

,,        benign 

,,        bony   . 

,,        carcinomatous 

,,        cartilaginous 

,,        chronic  mammary 

, ,        encysted 

,,        fibrous 

,,        fatty  . 

,,        glandular 

,,        horny 

,,        malignant 

,,        painful  subcutaneous 

, ,        sarcomatous 

,,        solid   . 

ULCERATION      . 
,,  of  bone 

,,  of  cartilage 

, ,  of  the  great  toe 

Ulcer,  how  to  strap  an 
Ulcers,  healthy 

,,      indolent 

,,       inflamed 

, ,       irritable 

. ,       of  the  cornea 

,,      of  the  rectum 

,,       phagedaenic    . 

,,      rodent  . 

, ,       varicose 

,,       weak    . 
Ulna,  fracture  of  the 
Ulnar  artery,  ligature  of  th( 
Umbilical  hei'nia 
Union,  immediate 

,,       by  the  first  intention 

.,       by  the  second  intention 
Uijper-arm,  amputation  through  the 
Urethra,  stricture  of  the     . 


INDEX. 


443 


l^rethritis 
[Trethrotomy     . 
Urinary  abscess 

,,       deposits 

,,       fistula 
Urine,  extravasation  of 
,,      retention  of     . 

TT^ARICOCELE 
'      Varicose  ulcers  . 
,,        veins    . 
Varix         .... 
Veins,  inflammation  of  (phlebitis) 
Venesection 
Vesico-va2;inal  fistula 


WAISTCOAT,  strait 
''     Warts,  simjjle  . 
,,      venereal 
"Whitlow  (paronychia) 
White  swelling  (scrofulous  disease 
Wounds 

„       by  irritant  poisons 

,,       contused 

, ,       dissection 

,,       gunshot  . 

,,       incised   . 

,,       lacerated 

,,       of  joints 

, ,       of  the  brain    . 

,,       poisoned 

,,       punctured 
Wrist,  amputation  at  the 

,,      dislocation  at  the 

,,      excision  of  the  . 
Wry-neck  (torticollis) 


of  joints) 


PAGE 

339 
308 
31-2 
316 
312 
311 
303 

330 

99 
203 
203 
202 
373 
337 

81 

27 

341 

105 

178 

57 

72 

60 

70 

62 

57 

60 

183 

211 

67 

61 

393 

189 

387 

266 


THE  END. 


TKINIKU    BY    BALLANTYNii   AND    HANSON 
LONDON    AND    EDINBURGH 


/ 


:f5^ 


i?^5 


